Tissue-based diagnosis of systemic amyloidosis: Experience of the informal diagnostic center at Uppsala University Hospital
Diagnosis of systemic amyloidosis is a clinical challenge and usually relies on a tissue biopsy. We have developed diagnostic methods based on the presence of amyloid deposits in abdominal subcutaneous fat tissue. This tissue is also used to determine the biochemical type of amyloidosis, performed by western blot and immunohistochemical analyses with the aid of in-house developed rabbit antisera and mouse monoclonal antibodies. Mass spectrometric methods are under development for selected cases. The diagnostic outcome for 2018-2020 was studied. During this period, we obtained 1,562 biopsies, of which 1,397 were unfixed subcutaneous fat tissue with varying degrees of suspicion of systemic amyloidosis. Of these, 440 contained amyloid deposits. The biochemical nature of the amyloid was determined by western blot analysis in 319 specimens and by immunohistochemistry in further 51 cases.
2. Benson MD, Buxbaum JN, Eisenberg DS, Merlini G, Saraiva MJM, Sekijima Y, et al. Amyloid nomenclature 2020: update and recommendations by the International Society of Amyloidosis (ISA) Nomenclature Committee. Amyloid. 2020;27(4):217–22.
3. Jarrett JT, Lansbury PT. Seeding “one-dimensional crystallization” of amyloid: a pathogenic mechanism in Alzheimer´s disease and scrapie? Cell. 1993;73(6):1055–8.
4. Pitkänen P, Westermark P, Cornwell GG III. Senile systemic amyloidosis. Am J Path. 1984;117(3)391–9.
5. Gertz M, Adams D, Ando Y, Beirão JM, Bokhari S, Coelho T, et al. Avoiding misdiagnosis: expert consensus recommendations for the suspicion and diagnosis of transthyretin amyloidosis for the general practitioner. BMC Fam Pract 2020;21(1):198.
6. Damy T, Adams D, Bridoux F, Grateau G, Planté-Bordeneuve V, Ghiron Y, et al. Amyloidosis from the patient perspective: the French daily impact of amyloidosis study. Amyloid. 2022;In press. doi: 10.1080/13506129.2022.2035354
7. Westermark P. Occurrence of amyloid deposits in the skin in secondary systemic amyloidosis. Acta Path Microbiol Scand A. 1972;80(6): 718–20.
8. Westermark P. Skin involvement in secondary amyloidosis. Acta Path Microbiol Immunol Scand A. 1971;79(1):79–80.
9. Schilder P. Über die amyloide Entartung der Haut. Frankf Z Path. 1909;3:782–94.
10. Brownstein MH, Helwig EB. The cutaneous amyloidoses. II. Systemic forms. Arch Dermatol. 1970;102(1):20–8.
11. Westermark P, Stenkvist B. Diagnosis of secondary generalized amyloidosis by fine needle biopsy of the skin. Acta Med Scand. 1971;190(5):453–4.
12. Gafni J, Sohar E. Rectal biopsy for the diagnosis of amyloidosis. Am J Med Sci. 1960;240:332–6.
13. Westermark P, Stenkvist B. A new method for the diagnosis of systemic amyloidosis. Arch Intern Med. 1973;132(4):522–3.
14. Gertz MA, Li CY, Shirahama T, Kyle RA. Utility of subcutaneous fat aspiration for the diagnosis of systemic amyloidosis (immunoglobulin light chain). Arch Intern Med. 1988;148(4):929–33.
15. van Gameren II, Hazenberg BP, Bijzet J, van Rijswijk MH. Diagnostic accuracy of subcutaneous abdominal fat tissue aspiration for detecting systemic amyloidosis and its utility in clinical practice. Arthritis Rheum. 2006;54(6):2015–21.
16. Miyazaki K, Kawai S, Suzuki K. Abdominal subcutaneous fat pad aspiration and bone marrow examination for the diagnosis of AL amyloidosis: the reliability of immunohistochemistry. Int J Hematol. 2015;102(3):289–95.
17. Olsen KE, Sletten K, Westermark P. The use of subcutaneous fat tissue for amyloid typing by enzyme-linked immunosorbent assay. Am J Clin Path. 1999;111(3):355–62.
18. Paulsson Rokke H, Sadat Gousheh N, Westermark P, Suhr OB, Anan I, Ihse E, et al. Abdominal fat pad biopsies exhibit good diagnostic accuracy in patients with suspected transthyretin amyloidosis. Orphanet J Rare Dis. 2020;15(1):278.
19. Westermark P, Davey E, Lindbom K, Enqvist S. Subcutaneous fat tissue for diagnosis and studies of systemic amyloidosis. Acta Histochem. 2006;108(1):209–13.
20. Westermark P. Subcutaneous adipose tissue biopsy for amyloid protein studies. Methods Mol Biol. 2012;849:363–71.
21. Benson MD, Berk JL, Dispenzieri A, Damy T, Gillmore JD, Hazenberg BP, et al. Tissue biopsy for the diagnosis of amyloidosis: experience from some centres. Amyloid. 2022;29(1):8–13.
22. Westermark P, Stenkvist B, Natvig JB, Olding-Stenkvist E. Demonstration of protein AA in subcutaneous fat tissue obtained by fine needle biopsy. Ann Rheum Dis. 1979;38(1):68–71.
23. Brambilla F, Lavatelli F, Di Silvestre D, Valentini V, Rossi R, Palladini G, et al. Reliable typing of systemic amyloidoses through proteomic analysis of subcutaneous adipose tissue. Blood. 2012;119(8):1844–7.
24. Vrana JA, Theis JD, Dasari S, Mereuta OM, Dispenzieri A, Zeldenrust SR, et al. Clinical diagnosis and typing of systemic amyloidosis in subcutaneous fat aspirates by mass spectrometry-based proteomics. Haematologica. 2014;99(7):1239–47.
25. Linke RP. On typing amyloidosis using immunohistochemistry. Detailled illustrations, review and a note on mass spectrometry. Prog Histochem Cytochem. 2012;47(2):61–132.
26. Linke RP, Meinel A, Chalcroft JP. Sensitive and reliable immunohistochemical typing of 21 different amyloid classes in 782 patients using amyloid-type specific antibodies directed against the amyloidotic conformation. With comments on the gold standard debate. Amyloid. 2017;24(sup1)(1):157–8.
27. Franklin EC, Pras M. Immunologic studies of water-soluble human amyloid fibrils. Comparative studies of eight amyloid preparations. J Exp Med. 1969;130(4):797–808.
28. Husby G, Natvig JB. Individual antigenic specificity and cross-reactions among amyloid preparations from different individuals. Clin Exp Immunol. 1972;10(4):635–47.
29. Gustavsson Å, Engström U, Westermark P. Mechanisms of transthyretin (TTR) amyloidogenesis: antigenic mapping of transthyretin purified from plasma and amyloid fibrils and within in situ tissue localizations. Am J Path. 1994;144(6):1301–11.
30. Westermark P, Benson L, Juul J, Sletten K. Use of subcutaneous abdominal fat biopsy specimen for detailed typing of amyloid fibril protein-AL by amino acid sequence analysis. J Clin Path. 1989;42(8):817–9.
31. Gilbertson JA, Botcher NA, Westermark P, Westermark GT, Smith LA, Jefferson ER, et al. A clinical validation study of an amyloid fibril specific anti-lambda immunoglobulin light chain monoclonal antibody for the diagnosis of AL amyloidosis in 150 cases. XVI International Symposium on Amyloidosis. 2016;Abstract PB83:297.
32. Vrana JA, Gamez JD, Madden BJ, Theis JD, Bergen III HR, Dogan A. Classification of amyloidosis by laser microdissection and mass spectrometry-based proteomic analysis in clinical biopsy specimens. Blood. 2009;114(24):4957–9.
33. Canetti D, Brambilla F, Rendell NB, Nocerino P, Gilbertson JA, Di Silvestre D, et al. Clinical amyloid typing by proteomics: Performance evaluation and data sharing between two centres. Molecules. 2021;26(7):1913.
34. Bergström J, Gustavsson Å, Hellman U, Sletten K, Murphy CL, Weiss DT, et al. Amyloid deposits in transthyretin-derived amyloidosis: cleaved transthyretin is associated with distinct amyloid morphology. J Pathol. 2005;206(2):224–32.
35. Ihse E, Ybo A, Suhr OB, Lindqvist P, Backman C, Westermark P. Amyloid fibril composition is related to the phenotype of hereditary transthyretin V30M amyloidosis. J Pathol. 2008;216(2):253–61.
36. Suhr OB, Lundgren E, Westermark P. One mutation, two distinct disease variants: unravelling the impact of transthyretin amyloid fibril composition. J Intern Med. 2017;281(4):337–47.
37. Stangou AJ, Hawkins PN, Heaton ND, Rela M, Monaghan M, Nihoyannopoulos P, et al. Progressive cardiac amyloidosis following liver transplantation for familial amyloid polyneuropathy: implications for amyloid fibrillogenesis. Transplantation. 1998;66(2):229–33.
38. Ihse E, Suhr OB, Hellman U, Westermark P. Variation in amount of wild-type transthyretin in different fibril and tissue types in ATTR amyloidosis. J Mol Med. 2011;89(2):171–80.
39. Ihse E, Rapezzi C, Merlini G, Ando Y, Suhr OB, Ikeda S, et al. Amyloid fibrils containing fragmented ATTR may be the standard fibril composition in ATTR amyloidosis. Amyloid. 2013;20(3):142–50.
40. Hazenberg BP, van Rijswijk MH. Where has secondary amyloid gone? Ann Rheum Dis. 2000;59(8):577–9.
41. Dische FE, Wernstedt C, Westermark GT, Westermark P, Pepys MB, Rennie JA, et al. Insulin as an amyloid-fibril protein at sites of repeated insulin injections in a diabetic patient. Diabetologia. 1988;31(3):158–61.
42. Nilsson MR. Insulin amyloid at injection sites of patients with diabetes. Amyloid. 2016;23(3):139–47.
43. Liepnieks JJ, Benson MD, Kluve-Beckerman B. Insulin: a diagnostic warning. Amyloid 2017;24(sup1):159–160.
44. Nagase T, Iwaya K, Iwaki Y, Kotake F, Uchida R, Oh-i T, et al. Insulin-derived amyloidosis and poor glycemic control: a case series. Am J Med. 2014;127(5):450–4.
45. Basset M, Hummedah K, Kimmich C, Veelken K, Dittrich T, Brandelik S, et al. Localized immunoglobulin light chain amyloidosis: Novel insights including prognostic factors for local progression. Am J Hematol. 2020;In press. doi: 10.1002/ajh.25915.
46. Westermark P. Localized AL amyloidosis: a suicidal neoplasm? Ups J Med Sci. 2012;117(2):244–50.
47. Ando Y, Adams D, Benson MD, Berk JL, Planté-Bordeneuve V, Coelho T, et al. Guidelines and new directions in the therapy and monitoring of ATTRv amyloidosis. Amyloid. 2022;In press. doi: 10.1080/13506129.2022.2052838.
48. Wechalekar AD, Cibeira MT, Gibbs SD, Jaccard A, Kumar S, Merlini G, et al. Guidelines for non-transplant chemotherapy for treatment of systemic AL amyloidosis: EHA-ISA working group. Amyloid. 2022;In press. doi: 10.1080/13506129.2022.2093635.
49. https://www.socialstyrelsen.se/kunskapsstod-och-regler/regler-och-riktlinjer/nationell-hogspecialiserad-vard/oversikt/systemisk-amyloidos/. 2022
50. Thelander U, Westermark GT, Antoni G, Estrada S, Zancanaro A, Ihse E, et al. Cardiac microcalcifications in transthyretin (ATTR) amyloidosis. Int J Cardiol. 2022;352(1):84–91.
51. Enqvist S, Sletten K, Stevens FJ, Hellman U, Westermark P. Germ line origin and somatic mutations determine the target tissues in systemic AL-amyloidosis. PLoS ONE. 2007;2:e981.
52. Enqvist S, Sletten K, Westermark P. Fibril protein fragmentation pattern in systemic AL-amyloidosis. J Pathol. 2009;219(4):473–80.
53. Baur J, Berghaus N, Schreiner S, Hegenbart U, Schönland SO, Wiese S, et al. Identification of AL proteins from 10 λ-AL amyloidosis patients by mass spectrometry extracted from abdominal fat and heart tissue. Amyloid. 2022;In press. doi: 10.1080/13506129.2022.2095618.
54. Bergström J, Murphy C, Eulitz M, Weiss DT, Westermark GT, Solomon A, et al. Codeposition of apolipoprotein A-IV and transthyretin in senile systemic (ATTR) amyloidosis. Biochem Biophys Res Commun. 2001;285(4):903–8.
55. Westermark GT, Sletten K, Westermark P. Alkali-degradation of amyloid: an ancient method useful for making monoclonal antibodies against amyloid fibril proteins. Scand J Immunol. 2009;70(6):535–40.
56. Bergström J. Apolipoprotein A-IV and transthyretin in Swedish forms of systemic amyloidosis. Thesis, Uppsala University. 2004.
57. Westermark GT, Ihse E, Westermark P. Development of mouse monoclonal antibodies against human amyloid fibril proteins for diagnostic and research purposes. Methods Mol Biol. 2018;1779:401–14.
58. Mucchiano GI, Häggqvist B, Sletten K, Westermark P. Apolipoprotein A-1-derived amyloid in atherosclerotic plaques of the human aorta. JPathol. 2001;193(2):270–5.
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors retain copyright of their work, with first publication rights granted to Upsala Medical Society. Read the full Copyright- and Licensing Statement.