CLINICOPATHOLOGIC

CONFERENCE

Serum and Urine Paraprotein and Filling Defects in the Spleen

Stenographic reports, edited by Philip E. Cryer, M.D. and John Kissane, M.D., of weekly clinicopathologic conferences held in Barnes and Wohl Hospitals, are published in each issue of the .Journal. These conferences are participated in jointly by members of the Departments of Internal Medicine and Pathology of Washington University School of Medicine. A 61 year old woman was admitted to Barnes Hospital on October 25, 1975, for diagnostic evaluation because of a “monoclonal gammopathy” of four years’ known duration. Increased serum globulin concentrations and a serum IgG paraprotein were first detected during hospitalization for cholecystectomy in December 1971. Roentgenograms of the skeleton and results of bone marrow examinations were normal at that time and at annual intervals thereafter. Aside from longstanding, nonprogressive low back pain, the patient was subjectively well until mid1974 when she noted increasing exertional dyspnea, ankle edema and a sensation of “tightness” in the chest-all of which diminished during therapy with digoxin and diuretics-and fatigue and diminished exercise tolerance which persisted. She lost 30 pounds in weight. Two weeks prior to her admission to Barnes Hospital she was hospitalized elsewhere because of left pleuritic chest pain and increased dyspnea. These symptoms diminished somewhat with additional diuretic administration. Additional medications included procainamide (1 g daily from June 1975). On examination, the patient was in no acute distress. The blood pressure was 120/70 mm Hg, the pulse rate 84/min, the temperature 36OC, the respiratory rate 18/min and the weight 53 kg. Positive findings included decreased thoracic expansion on the left and diminished breath sounds at the base of the left lung, an audible fourth heart sound and a grade 216 systolic murmur along the left sternal border. The maximum cardiac impulse was 2 cm lateral to the left midclavicular line in the sixth intercostal space, the liver was palpable 6 cm below the right costal margin with a percussion span of 14 cm, and the spleen tip was palpable. There was no edema. Two enlarged right axillary lymph nodes were noted by one examiner. Routine serum chemistries were normal aside from an alkaline phosphatase level of 250 mlU/ml and a creatinine level of 1.3 mg/lOO ml. The creatinine clearance was 47 ml/min. The serum cholesterol was 231 mg/lOO ml, the albumin 3.3 g/100 ml and the

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ing defects in the spleen. Computerized axial tomography of the abdomen confirmed the latter finding. Roentgenograms of the skeleton and intravenous urograms were within normal limits. The size of the left pleural effusion increased, and a thoracentesis was performed on the ninth hospital day. The thick yellow fluid contained 3.9 g/100 ml of protein; the glucose and amylase levels were normal. The pleural fluid cell count was 22,700/mm3 without acid and 1,800/mm3 with acid (11 per cent segmented neutrophils, 34 per cent lymphocytes and 55 per cent large mononuclear cells). Cytologic examination of the fluid for malignant cells was negative. On November formed. Figure 1. Computerized tomographic scan of the abdomen 6 cm inferior to the ziphoid after intravenous injection of 50 cc of Conrafl. Large negative filling defects in the spleen are seen (arrows) uric acid 6.9 mg/iOO ml. The hemoglobin level was 11.7 g/100 ml, the hematocrit value 41 per cent, the white blood cell count 12,400/mm3, the platelet count 900,000/mm3 and the reticulocyte count 3.0 per cent. Bone marrow examinations revealed 4 per cent and 5 per cent plasma cells on two occasions. Aside from 4-l- proteinuria, the urinalysis, including examination of the sediment, disclosed no abnormalities. Electrocardiographic findings included first degree atrioventricular block, low voltage in the limb leads, poor r-wave progression in the precordial leads and q waves in leads II, III and AVF. Cardiomegaly and a small left pleural effusion were demonstrated

on chest roentgenograms.

On serum protein electrophoresis the gamma globulin level was 1.8 g/100 ml. The serum immunoglobulin G (IgG) level was 1,632 mg/lOO ml (normal 645 to 1,300 mg/lOO ml), the immunoglobulin A (IgA) level was 179 mg/lOO ml (normal 48 to 295 mg/lOO ml) and the immunoglobulin M (IgM) level was 500 mg/lOO ml (normal The urine contained 8.3 g/24

77 to 364 mg/lOO ml). hours of protein includ-

ing 9.0 per cent gamma globulin. Immunoelectrophoresis of the serum and urine demonstrated the presence of an IgG paraprotein with lambda type light chains. The urine also contained free lambda light chains. Total hemolytic complement activity and levels of C’3 and C’4 in the serum were normal. Serum antinuclear antibodies were 3i- positive with homogeneous and rim staining. Anti-DNA antibodies were not detectable. Liver-spleen scans confirmed the presence of hepatosplenomegaly and demonstrated multiple fill-

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6,

1975,

an operation

was

per-

DISCUSSION

Dr. Charles Parker: In summary, this patient was found to have an IgG paraprotein in her serum in 1971. I suspect that the disease process which ultimately brought her to this hospital in 1975 had already started at that time, although the possibility of a benign monoclonal gammopathy and a subsequent unrelated illness also must be considered. In 1974 she experienced dyspnea on exertion and edema, and she was treated for congestive heart failure with partial relief of symptoms. She was admitted to this hospital in October 1975 because of continuing dyspnea and edema, and the recent onset of left lower chest pain. At this point in time she had multiple organ system involvement with clinical and laboratory manifestations referable to the kidney, spleen, heart, liver, lung, pleura and possibly lymph nodes. One important topic for discussion will be whether the same disease process was involving all these different organs or whether several unrelated diseases were present. We will begin with presentation of the roentgenograms by Dr. Forrest. br. John Forrest: The chest film obtained on admission showed slight to moderate cardiomegaly with slight blunting of the left costophrenic angle. A week later the patient had a large left pleural effusion. A week after that, after thoracentesis, the left pleural effusion was smaller. At that time there was a small right pleural effusion and increased prominence of septal lines. The roentgenograms of the chest would be compatible with congestive heart failure; in addition, some other cause of left pleuritis would have to be suspected. A radionuclide liver-spleen scan showed hepatosplenomegaly and filling defects in the spleen. An EMI computerized tomographic scan of the abdomen confirmed multiple defects in the spleen (Figure 1). Large splenic filling defects with splenomegaly are

SERUM AND URtNE PARAPROTEtN AN0 FtLLtNG DEFECTS IN THE SPLEEN

almost

always

ple abscesses

due to neoplasm. or infarcts

Occasionally,

can produce

multi-

this scan pat-

tern. In summary, there were roentgenographic findings of congestive heart failure and hepatosplenomegaly with splenic masses and associated left pleural effusion

suggesting

some

sort

of

neoplasm,

perhaps

lymphoma. Dr. Parker: Dr. Forrest, can nodular amyloid infiltration in the spleen cause a picture like this? Dr. Forrest: I have never seen such a case. I think it

has occurred,

as appeared

to be the case in this pa-

tient. For purposes of completeness, it should be noted that there are reports of immune complex nephritis and the neprotic syndrome occurring in association with chronic paraproteinemia and no apparent underlying disease [ 1,2], and it is conceivable that no clearly definable pathologic process will be demonstrated, either in the spleen or elsewhere. However, I believe this is unlikely, and in the remain-

would be rare. Dr. Parker: An intravenous urogram *as performed despite a long-standing history of paraproteinemia

der of my discussion I am going to assume that the pathologic findings will be positive. Another striking abnormality in this patient was the markedly positive test for antinuclear antibodies which, taken in association with the nephrotic syn-

and the recent demonstration of free immunoglobulin light chains in the urine. Are you concerned about intravenous infusions of contrast media in patients with known or suspected myeloma, or Bence Jones proteinuria, in view of the acute deterioration in renal

drome, necessitates that SLE be seriously considered. This possibility is heightened by the fact that the patient had received substantial doses of procainamide during the preceding four to five months. Moreover, light chain proteinuria is not unusual in

function

SLE; of course, symptomatic pleural involvement is one of the hallmarks of the disease. On the other hand, my own view is that SLE is relatively unlikely for a number of reasons: (1) It would be unusual for idiopathic SLE to begin at this age. Moreover, although procainamide-induced lupus must be considered, renal involvement is unusual in this condition.

that occasionally

occurs,

or do you believe

that this complication has been overemphasized? Dr. Forrest: If the patient is dehydrated, precipitation of the abnormal proteins in the kidney can lead to acute renal failure. As long as one is aware of this possibility and keeps the patient well hydrated, I do not think it is a significant problem. The urogram was normal as was a limited

meta-

static bone survey. Dr. Parker: Thank you very much. This patient fulfilled most of the classic criteria for diagnosis of the nephrotic syndrome, including a urinary protein excretion causes

of greater than 8 g/day. of the nephrotic syndrome,

Of the various the ones I would

consider most seriously in this patient are systemic lupus erythematosus (SLE), amyloidosis and malignancy, myeloma or some other forms of plasma cell myeloma or lymphoma. The possibility of renal vein thrombosis arises in a patient with the nephrotic syndrome, edema and manifestations in the left lung consistent with pulmonary infarction. On the other hand, I would have expected to see enlarged and otherwise abnormal kidneys on the urograms and I think that diagnosis can be excluded. As far as the renal picture per se is concerned I do not think it permits us to distinguish between the various diagnostic possibilities. Telescoping of the urinary sediment occurs to a greater extent in SLE than in the other diseases mentioned, but its absence is not a strong point against that diagnosis. Enlargement of the kidneys is seen in several of the diseases which produce the nephrotic syndrome, and it is a particularly common finding in the early stages of renal amyloidosis. However, with the passage of time it is not unusual to find normal or even small kidneys; this is particularly true after partial renal decompensation

(2) There are no manifestations in other organ systems that would point toward this diagnosis as, for example, in the joints, skin or nervous The paraproteinemia does not fit very

system. (3) well either.

Somewhat to my surprise, I was unable to find SLE listed in several collected series of paraproteinemia, even though there were several patients with rheumatoid arthritis. (4) Finally, the presence of homogeneous immunoglobulin light chains in the urine cannot be used to argue for SLE because the light chain proteinuria in this condition is polyclonal in nature [3,4]. Dr. Hahn, would you consider further the clinical picture of procainamide-induced lupus and also comment on whether or not you agree that SLE is relatively unlikely in this patient? Dr. Bevra Hahn: I certainly agree that this lady does not have primary systemic lupus erythematosus (SLE). It would be unusual for SLE to occur in her age group. The absence of peripheral polyarthritis, skin manifestations, leukopenia, and of hypocomplementemia and anti-DNA antibodies associated with the renal disease, all make the diagnosis of primary SLE unlikely. The possibility of procainamide-induced lupus must be seriously entertained. Once a person is started on procainamide therapy, the interpretation of antinuclear antibody (ANA) tests becomes very difficult. With standard doses of procainamide (2 g/ day), positive ANA tests will develop in approximate-

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half of the patients within two to nine months [S]. In our experience, the ANA titers are usually high

ly

(1:90 or greater),

and the patterns

seen using rat kid-

ney as substrate are usually homogeneous and rim. The rim pattern correlates with antibodies to DNA, which may be present in procainamideor hydralazine-induced lupus [6,7] but are probably directed against single-stranded DNA rather than native DNA, in contrast to true SLE [6]. This patient had pleural effusions, which occur in the majority of patients with procainamide-induced lupus, but she did not have arthralgias, which occur in nearly 90 per cent [6,8]. Nephropathy is very unusual in procainamideinduced lupus, and monoclonal gammopathies have not been described. Therefore, I am confident that we can attribute the positive ANA test to procainamide therapy. The pleural effusions might also be related to that drug. Primary SLE is very unlikely. We must turn to other diagnostic possibilities to explain the dysgammaglobulinemia, hepatosplenomegaly and nephropathy. Dr. Parker: Thank you. As you pointed out to me, there are several reports of procainamide-induced nephritis in the literature. Rutherford [9] described persons receiving procainamide, with blood urea nitrogen levels above 150 mg/lOO ml which rapidly returned to normal after withdrawal of the drug. Unfortunately, none of them had a renal biopsy, so we cannot say for sure what was going on pathologically in the kidney. Thus, renal involvement probably does occur with procainamide therapy, but it is rare; for a variety of reasons, the other diagnoses under consideration seem much more likely. It may be worth mentioning that there is at least one known example of a human IgG paraprotein with binding specificity for DNA [lo] raising the the antinuclear antibody in by the paraprotein itself. treatment with procainamide likely explanation. As Dr. Forrest indicated,

interesting possibility that this patient was produced However, the course of provides a much more multiple

filling

defects

in

the spleen were seen on conventional scans and with computerized scans (Figure 1). In the absence of fever or leukocytosis, I cannot make a diagnosis of splenic abscess despite the fact that multiple abscesses could produce a pattern similar to that seen on the spleen scans and could also give rise to the pleural inflammation that this patient appears to have. In someone who has chronic congestive heart failure, cardiac enlargement, has been under treatment previously for cardiac arrhythmias and has had recent pain of a pleuritic nature in the left lower anterior portion of the chest, splenic infarction has to be considered. However, in the absence of arterial embolism elsewhere, a known recent episode of ar-

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rhythmia, a recent myocardial infarction or a wedgeshaped configuration to the defects in the spleen, it is difficult to make this diagnosis. In addition, the symptoms are equally consistent with pulmonary infarction, which would also explain the left pleural effusion. Dr. Forrest admitted that amyloid might conceivably produce filling defects of the type seen in this patient, but he thought that this would be very unusual. Although I have no doubt that he is on solid ground statistically, I would also point out that amyloid involvement of the spleen is very common in systemic amyloidosis and that although organ infiltration by amyloid ordinarily is diffuse, nodular infiltration can occur, particularly in the skin and lungs. Moreover, in a review of primary amyloidosis, a liver scan was presented which showed a large filling defect suggestive of tumor [ 111. At autopsy, this turned out to be an area of amyloid infiltration with almost complete displacement of normal tissue from the area. So, the abnormality seen in the spleen could be caused by amyloid itself. However, the scan is much more suggestive of tumor, especially lymphoma. In recent years, a number of examples of what appears to be primary lymphomatous involvement of the spleen have been recognized. The most common pathologic diagnoses have been reticular cell sarcoma, Hodgkin’s disease or lymphosarcoma, although other types of lymphoreticular malignancies have also been seen. In a person who is known to have a paraprotein abnormality, plasmacytoma involving the spleen must also be considered. Taking the spleen scan by itself, lymphoma is the most likely diagnosis as Dr. Forrest has already indicated. However, as I will discuss in a few minutes, other considerations militate against this diagnosis. In addition to abnormalities in the spleen and kidneys, this patient had changes referable to the cardiovascular system, lungs and the liver. Dr. Atkinson, can you put the clinical picture together as a single disease process or do you believe that we are dealing with two or more unrelated diseases? Dr. John Atkinson: The most prominent symptoms were those caused by cardiovascular disease, and their description suggests both congestive heart failure and angina pectoris. Treatment for congestive heart failure was apparently associated with considerable improvement. Physical examination of the heart revealed modest cardiomegaly, a fourth heart sound and a nondescript 2/6 systolic ejection murmur-nonspecific findings of little differential diagnostic value. The electrocardiogram demonstrated sinus rhythm, first degree heart block, q waves in leads II, Ill and AVF, poor r-wave progression across the precordium and, of special importance to the diagnosis of amyloidosis, low voltage. However, none

SERUM AND URINE PARAPROTEIN AND FILLING DEFECTS IN THE SPLEEN

of these findings is specific for amyloidosis as they may be found in any diffuse myocardial disease process. The differential diagnosis is between atherosclerotic cardiovascular disease and an infiltrative cardiomyopathy with amyloidosis being of obvious concern in this patient. Additional noninvasive diagnostic procedures would probably not have definitely separated these two entities. This not uncommon, and a difficult diagnostic problem could have been settled by angiography and/or, as is being done in some centers, myocardial biopsy. I favor amyloidosis in this patient, and, in view of more readily available pathologic material elsewhere, would not have performed an invasive cardiac procedure. This patient presented with left-sided pleuritic chest pain, decreased breath sounds at the base of the left lung and a small left-sided pleural effusion which increased considerably over the first two weeks of hospitalization. Examination of the fluid revealed it to be an exudate and to contain no malignant cells. The 55 per cent large cells described in the protocol presumably were of mesothelial origin. The clinical presentation and laboratory characterization of the fluid point to a causative process other than congestive heart failure or the nephrotic syndrome. Three diagnoses need to be considered: (1) pulmonary emboli, (2) tumor involving the pleura and (3) serositis associated with procainamide-induced lupus. The last has been adequately discussed and, for the reasons listed previously, essentially ruled out in this patient. Pulmonary embolization with infarction is an attractive possibility in view of the acute onset and clinical setting of congestive heart failure, chronic debilitating illness and nephrotic syndrome. The nephrotic syndrome could be caused by renal vein thrombosis or this patient could have had amyloidosis involving the kidneys. There is an increased frequency of renal vein thrombosis in patients with amyloidosis. A second and equally likely possibility is that there was tumor involving the pleura. The radiologist believes that tumor will be found in the spleen and that malignant cells could reach the left pleura via lymphatics. The negative pleural cytology is against, but by no means rules out, pleural involvement with tumor. Depending upon the degree of concern over the diagnosis of pulmonary emboli, one would be tempted to perform a ventilation/perfusion scan or pulmonary angiography. Since pulmonary embolus is a potentially life-threatening but treatable process, more aggressive work-up of this possibility may have been indicated. A diffusively enlarged liver was present. Liver function tests were mildly abnormal with modestly increased serum alkaline phosphatase (presumably of hepatic origin) and borderline high serum enzyme

levels.

However,

the serum

bilirubin

was normal

and

the serum albumin was 3.3 g/100 ml despite considerable proteinuria. Also, the third component of complement, which is made by the hepatocytes, was not depressed. Therefore, the liver appeared to have relatively normal synthetic and degradative capacity. These findings would suggest infiltration with either tumor or amyloid. I doubt if this patient had sufficient congestive heart failure to explain the hepatic abnormalities. In summary, I think this patient has amyloidosis involving the heart and probably the liver as well, and either tumor or pulmonary emboli to account for the pleural effusion. At the time of exploratory laparotomy, a wedge liver biopsy was probably performed so the answer should be available. Dr. Parker: Thank you. Let us now consider the abnormal proteins present in the serum and urine of this patient. A homogeneous immunoglobulin is demonstrable both in the serum and urine. In addition, homogeneous, lambda type immunoglobulin light chains are present in the urine. Interestingly, the total serum IgM level is elevated raising the possibility of a double gammopathy involving both IgM and IgG. Although no definite evidence for an IgM paraprotein is available, generalized increases in IgM are unusual in association with IgG paraproteinemias, and further studies appear warranted. Unfortunately, we do not know the quantity of IgG paraprotein present either in 1975 or in 1971, when the abnormality was first discovered; therefore it is not clear whether production is increasing or not. Nor do we know the absolute quantity of free light chains excreted in the urine. In the presence of paraproteinemia, one thinks immediately of multiple myeloma. I do not think we have enough evidence to make a diagnosis of myeloma considering the repeated negative bone marrow aspirations and bone films. Plasmacytoma without bone marrow involvement also must be considered, although this is an unusual condition and there is no evidence that the magnitude of the paraproteinemia is increasing. Primary amyloidosis is now quite clearly implicated as one of the conditions associated and seemingly fits quite well in terms of the magnitude and duration of the paraprotein disorder. Another diagnosis under consideration in this patient, lymphoma, also is associated with paraproteinemia, but not ordinarily as a presenting manifestation. As Dr. Eisen will comment in more detail in a moment, there are the so-called benign monoclonal gammopathies [ 121 in which persons exhibit circulating paraproteins for years, often in relatively low concentrations [2] in the absence of recognizable underlying disease. However, there are patients who

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appeared originally to have benign monoclonal gammopathy, but in whom after long term follow-up study (7 to 16 years) multiple myeloma eventually developed [ 131. However, Bence Jones proteinuria occurs only in a minority of patients with apparent benign monoclonal gammopathy, and the quantities are usually quite small [ 131. Despite our inability to make a diagnosis of double gammopathy in this patient, it may be worth briefly discussing the various clinical manifestations exhibited by patients who have this condition. Some 26 patients, representing about 0.5 per cent of patients with M-type proteins in series suitable for analysis [ 141, with double gammopathy have been described. The clinical picture varies widely resembling multiple myeloma, macroglobulinemia, plasma cell leukemia or collagen vascular disease either singly or in combination. Three patients have had plasmacytoma. Obviously, there is nothing sufficiently distinctive about the clinical manifestations of double gammopathy to make us doubt or strongly suspect its existence in the patient under discussion. We will discuss the problem of monoclonal gammopathy in greater detail. Dr. Eisen, would you comment on the paraproteinemia present in this patient? Do you think we are dealing with a benign monoclonal gammopathy which is unrelated to her recent clinical deterioration or is this lymphoma or primary amyloidosis? Dr.

Seth Eisen: I would

like to distinguish

between

benign and malignant monoclonal gammopathy. By malignant monoclonal gammopathy, I mean diseases in four categories: multiple myeloma, Waldenstrom’s macroglobulinemia, heavy chain disease and various lymphoreticular malignancies. Benign gammopathies include diseases other than those just mentioned. However, benign should not be confused with asymptomatic, since some “benign” paraproteins may cause considerable clinical discomfort. For example, some “benign” cryoproteins may precipitate widespread ischemic symptoms. A number of criteria have been investigated for their ability to differentiate benign from malignant gammopathy. As one would predict, the higher the hemoglobin concentration the more likely the process is benign. Hemoglobin levels above 12 g/100 ml generally imply a more favorable outcome. Also, patients with benign gammopathies most often have fewer than 5 per cent plasma cells in the bone marrow. Maintenance of the serum albumin concentration above 3 g/100 ml is more consistent with a benign process as is the continued presence of normal amounts of immunoglobulin other than the monoclonal paraprotein. The type of paraprotein is also significant in evaluating the patient. The most common paraprotein associated with a benign course, as determined by long-term and au-

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topsy follow-up, is IgG. Increasing in frequency with increasing age, somewhat under 1 per cent of the normal adult population has an IgG paraprotein. Similarly, about 0.5 per cent of the population has an IgA paraprotein, but an IgM paraprotein is usually associated with a malignant process. The concentration of the paraprotein is important; the greater the concentration the greater the likelihood of an associated malignancy. One g/ml is generally the cut-off value, but several other cut-off values have been proposed. The .presence of Bence Jones proteinuria is significant. About a quarter of patients with benign monoclonal gammopathy have Bence Jones proteinuria but only in very small amounts. A value above 150 mg Bence Jones protein/24 hours is more consistent with a malignant process. Even after evaluating patients by all these criteria, a significant number cannot be easily allocated to one category or the other. In such cases, the patient should be followed with frequent reevaluations for evidence of malignant deterioration. One other novel approach to differentiating benign from malignant processes should be mentioned. Lindstrom and co-workers [ 15] recently quantitated the percentage of B lymphocytes in the peripheral blood of patients with benign and malignant gammopathy. In benign gammopathies about 20 per cent of the peripheral lymphocytes fluoresced with fluorescinated anti-immunoglobulin antiserums whereas fewer than 10 per cent of the lymphocytes obtained from patients with malignant gammopathies did. In addition, rabbits were immunized with purified paraprotein obtained from several of the patients and anti-idiotypic antiserum was prepared. Using the fluorescinated technic, about 20 per cent of the lymphocytes from patients with malignant gammopathy fluoresced with the anti-idiotypic antibody to autologous paraprotein whereas only 5 per cent of the lymphocytes from patients with benign gammopathy did. Although the differences were striking, the numbers of patients tested were small and the antibody preparation technic was too arduous for wide clinical application. Our patient’s hemoglobin level is near normal, bone marrow examinations have consistently demonstrated few plasma cells, and the serum albumin is fairly well-maintained. Although the data are incomplete, the non-monoclonal immunoglobulins also appear to be near normal. An IgG paraprotein such as this patient’s is most commonly associated with a benign course. More information about possible clonal characteristics of the patient’s elevated IgM level would be helpful, but it is not available. I suspect the IgM is polyclonal and therefore more likely benign. Quantitation of the patient’s Bence Jones proteinuria and IgG monoclonal spike is similarly unavailable. As Dr. Parker mentioned, it would have been very help-

SERUM AND URINE PARAPROTEIN AND FILLING DEFECTS IN THE SPLEEN

ful to compare the amount of the paraprotein present in 1971 with the amount present during the present

tymphoma is concerned, there is an unusual but not

hospitalization.

a survey carried out by one of his residents that showed that of 60 patients with Hodgkin’s disease subjected to autopsy at the Massachusetts General Hospital over a period of years, five had had complicating amyloidosis. A comparable or somewhat lower incidence of amyloidosis in association with Hodgkin’s disease has been seen in other series. In my view, this patient does indeed have amyloidosis; I would now like to consider whether this was

rare association.

A recent increase would have point-

ed strongly towards a malignant process. The patient’s five year course is somewhat against a malignancy. If this were my patient, I would have recommended a laparotomy to diagnose the splenic process. Although a number of aspects of this patient’s gammopathy indicate a benign etiology, the total disease spectrum is most consistent with a lymphoreticular malignancy and I think that this is a malignant

In 1949, Dr. Castleman [20] quoted

primary amyloidosis or amyloidosis in association with lymphoma or plasmacytoma. If we assume that the heart, liver, kidneys and spleen are infiltrated with amyloid, this distribution fits a little better with primary amyloidosis or secondary amyloidosis associated with plasma cell neoplasm than with the usual forms of secondary amyloidosis. However, many exceptions occur and the distribution of organs involved is not a really useful diagnostic point in itself. I am going to argue that, despite the filling defects in the spleen, this patient probably has primary amyloidosis. In taking this position I am placing considerable emphasis on the long-standing history and char-

monoclonal gammopathy. Dr. Parker: Thank you. We have been talking about lymphoma throughout the conference, and there are a number of possible clues to that diagnosis. By far the most important are the presence of filling defects in the spleen and, possibly, the paraproteinemia. In addition, lymphoma is sometimes associated with amyloidosis as will be discussed in a moment. Less impressive lines of evidence include the 30 pound weight loss, which may or may not be related in part to diuresis, and the enlarged axillary lymph nodes noted by one but not all of the examiners. The serum uric acid level was elevated on at least one occasion, but this may have been due to early renal decompensation. There also was thrombocytosis of variable severity which has been described in lymphoma, but which also occurs as a nonspecific manifestation of inflammation and is sometimes seen in association with primary amyloidosis. The

acter of the paraprotein abnormality. A few documented examples are available, but I suspect that it will turn out to be much more common to have a long-sustained paraproteinemia before obvious clinical manifestations of organ involvement in primary amyloidosis than in lymphoma. In fact, in the various series I was able to find in which paraproteinemia

nephrotic syndrome is a well recognized but unusual complication of lymphoma both with and without associated amyloidosis. Manifestations usually appear after the tumor is clinically obvious, but they can in rare circumstances occur first. In some instances, clinical improvement has been noted in the nephrotic syndrome after the institution of effective antineoplastic treatment. Although there are only about 30 reported cases in which the patients have both lymphoma and the nephrotic syndrome, but do not also have amyloidosis, nearly all have appeared in the past four or five years and the association may not be as rare as would otherwise appear. In a portion of these cases, immunoglobulins or complement deposits have been identified in the glomeruli [ 16,171 suggesting that a tumor-specific or tumor-associated antigen is being released into the circulation, complexing with antibody and producing classic immunecomplex nephritis. However, in a number of well-

had been seen in association with lymphoma, I was not able to identify a single instance in which paraproteinemia had been demonstrated before clinical manifestations of the tumor [ 12,21,22]. Although I suspect that there will be exceptions to this general rule, it is difficult for me to believe that this patient has had subclinical lymphoma for the past four years and that only now is she beginning to have clinical symptoms referable to the tumor. In not one of Osserman and Takatsuki’s series of 31 cases of paraproteinemia associated with malignancy of the lymphoreticular system [23] were free light chains present in the urine. Although other series suggest that Bence Jones proteinemia can occur in this situation [ 131, it is unusual. In contrast, in both primary amyloidosis and plasma cell tumors, intact paraproteins and free paraprotein light chains are frequently demonstrable in the same patient. A final point has to do with the different types of amyloid infiltration that are seen in primary and secondary amyloidosis. In primary amyloidosis and amyloidosis associated with plasma cell tumors, the amyloid fibrils are derived from the N terminal end of immunoglobulin light chains, presumably as a result of partial degradation of circulating or locally secreted molecules of intact

studied cases, although there was a considerable amount of nonspecific tubular and glomerular damage, immune complexes could not be demonstrated [ 18,191. Although immune complexes might have been present originally and no longer demonstrable, another mechanism may be involved in these patients. As far as amyloidosis in combination with

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paraprotein or paraprotein light chains [24-261. Thus, in both of these conditions paraproteins appear to have immediate pathogenetic significance in the formation of the amyloid lesion. In the one case of lymphoma and amyloidosis in which the amyloid protein was partially sequenced as well as analyzed immunologically [27,28], it was not a recognizable immunoglobulin fragment at all, but rather the socalled amyloid-A protein. This protein has also been found in other types of secondary amyloidosis in man, in experimental amyloidosis in animals and in amyioid infiltrates associated with familial Mediterranean fever [27,29,30]. Moreover, although lsobe and Osserman have reported that monoclonal immunoglobulins are commonly present in the serum of human beings with secondary amyloidosis [31], other investigators have found little or no evidence for such an association [32]. Thus, even though amyloidosis develops in patients with lymphoma, they are not necessarily present in the same person and, in contrast to the situation in primary amyloidosis, it is not clear that immunoglobulin paraprotein fragments are important in the pathogenesis of the lesion; in a patient who has both amyloidosis and paraproteinemia, either primary amyloidosis or a plasma cell tumor is likely to be present. Therefore, despite the spleen scan, I believe this is primary amyloidosis or less likely amyloidosis associated with plasmacytoma in the spleen. I will now ask our other discussants what they think the diagnosis is? Dr. Atkinson: I am impressed with the spleen scan and have to go with lymphoma and amyloidosis. with Dr. Atkinson but I think that

Dr. Eisen: I agree

paraprotein precipitating in the glomeruli is causing the nephrotic syndrome rather than amyloidosis. Dr. Hahn: I favor primary amyloidosis. Dr. Parker: We are privileged to have Dr. Benjamin Castleman of the Harvard Medical School and the Massachusetts General Hospital present the patho-

Figure 2. Transverse section of the spleen showing multiple infarcts in a shiny dense splenic parenchyma.

Dr. Castleman: What about liver? liver.

If it is amyloid,

placing a needle in her you would probably find it in the

Dr. Parker: Livers infiltrated with amyloid have been known to fracture during biopsy. Unless lymphoma as well as amyloid were present in the liver biopsy specimen, the nature of the process in the spleen would have continued to be in doubt. Dr. Castleman: The surgeon performed a staging laparotomy, removing the spleen and a lymph node, and biopsying the liver and kidneys. On cross section of the spleen (Figure 2) the geographic pattern of the shape of the lesions and their peripheral location are characteristic infarcts. Of course, one ordinarily thinks of infarction in a patient with leukemia. I have never seen infarcts in the spleen associated with amyloidosis. On the other

logic findings. PATHOLOGIC

DlSCtJSSlON

Dr. Benjamin Castleman: Dr. Parker, are you so sure of your diagnosis

that you would not advise

a laparot-

omy?

Dr. Parker: It is always difficult to know what you would have done if you had had a decision you do not the now have. If this patient does have amyloidosis, diagnosis could probably have been made by rectal biopsy. However, in lieu of structural studies on the amyloid protein itself, this would not distinguish between primary and secondary amyloidosis and we would still have the problem of the multiple filling defects in the spleen and the possibility of a treatable tumor. Therefore, I might well have had this patient come to laparotomy.

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Low power microphotograph of the spleen Figure 3. with the parenchyma replaced by amyloid. Amyloid is also seen in the wall of small arteries. Hematoxylin and eo&n stain, original magnification X 150, reduced by 50 per cent.

SERUM AND URINE PARAPROTEIN AND FILLING DEFECTS IN THE SPLEEN

plasmacytosis, and I found one focus of amyloid with proliferation of plasma cells around it (Figure 5). With this amount

of amyloidosis,

there

is probably

amyloidosis in the heart. Dr. Parker: Would the ages of the infarcts in the spleen be consistent with her history of pain for two weeks? Dr. Castleman: I should think so. There was no real walling of the infarcts, so they could have been about two weeks old. Dr. Mancilla has some pictures of the fluorescent studies of the kidney. Dr. Raul Mancilla-Jimenez: lmmunofluorescent studies with monospecific antiserum to heavy and light chains were performed in sections of kidney and Wedge biopsy specimens of the liver showing Figure 4. clusters of thick walled vessels. Amyloid was demonstrated by special stains. Hematoxylin and eosin stain, original magnification X 90, reduced by 50 per cent.

hand, if we look at the splenic tissue itself, it certainly has a glassy appearance that would suggest amyloidosis. Microscopically, the focal lesions prove to be infarcts and most of the splenic pulp is infiltrated and replaced by amyloid (Figure 3). This type of splenic involvement with amyloidosis is usually seen in secondary amyloidosis, but we know it can also occur in patients with primary amyloidosis. In the primary type, amyloid infiltration of vessel walls is the characteristic finding: this was also present in this spleen as well as in the vessels of the liver (Figure 4) and kidney. In addition to the small vessel infiltration, amyloid involved the walls of the sinusoids of the liver and many of the glomerular capillaries. In the small retroperitoneal node, there was a small area of para-amyloid material. A bone marrow biopsy specimen was reported as showing about a 5 per cent

Figure 5. Focus of amyloid material surrounded by a few plasma cells in a bone marrow biopsy specimen. Hematoxylin and eosin stain, original magnification X 350, reduced by 50 per cent.

spleen. In the kidney, there was bright fluorescence of mesangial areas and of blood vessels with antiserum to IgG and to lambda light chains, which are the abnormal immunoglobulins found in this patient. Weaker staining was also seen with antiserum to IgA, C3 and kappa light chains. Staining for IgM, IgE and fibrinogen was negative. Similar staining patterns were found in sections of spleen. The immunofluorescent deposits in both organs were found in sites of amyloid deposition, suggesting that they are nonspecific and secondary to disruption of the tissue architecture imposed by the presence of the amyloid fibrils. However, the possibility exists that some of these materials, particularly the light chains, are structurally related to the amyloid substance. The renal pathology associated with benign monoclonal gammapathies seems to be heterogeneous [33]. It includes amyloidosis, proliferative glomerulonephritis and glomerulosclerosis. In some of these cases, the abnormal paraprotein has been demonstrated in the glomerular lesions by immunofluorescent technics, however, in two cases of benign monoclonal gammapathy complicated by amyloidosis, reported by Verroust and co-workers, no immunoglobulins were found [33]. A practical question in this case is whether the course of the renal disease is going to be worsened by the addition of an abnormal protein to the amyloid deposits. Dr. Castleman: Dr. Parker how would you treat this patient? Dr. Parker: Eventually patients like this may well be treated with selective immunoabsorbents containing antibodies directed toward idiotypic determinants on the paraprotein in an effart to eliminate the presumed source of amyloid deposits. We have carried out some preliminary work in vivo using nylon tubing coupled to model protein antigens as an immunoabsorbent, and the results appear promising [34]. As far as the immediate future is concerned, repeated plasmapheresis or attempts to interfere with plasma cell function are both worth considering. Some people believe that even at this stage, the patient should

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CI_lNlCOPATHOLOGlCCONFERENCE

be treated as if she had myeloma on the well-founded assumption that plasma cells are producing the paraprotein and that if the paraprotein secretion is inhibited less amyioid will be deposited. So the same types of cytotoxic agents that are effective in myeloma might be considered here. A very interesting preliminary report several years ago stated that colchitine strikingly inhibited casein-induced amyloid deposition phases

in mice, provided of induction [35].

it was given during early Since relatively nontoxic

concentrations of colchicine were effective, and it is already in the human therapeutic armamentarium, therapeutic trials in human beings may be warranted. However, since casein-induced amyloidosis is an experimental model for secondary amyloidosis, it might be logical to initiate such studies in the secondary form of the disease. Dr. Tim Sullivan: Is there any evidence that amyloid deposits ever contain heavy chains? Dr. Parker: Not to my knowledge.

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