UNRAVELING THE LABYRINTH OF SINUSOIDAL DEPOSITS IN THE LIVER OF A 68-YEAR-OLD

MAN

Taofic Mounajjed, M.D

Clinical History A 68 year-old man presented with chronic recurrent pleural

effusions

During laboratory workup, abnormal liver biochemistries were discovered

Past medical history End stage renal disease (on dialysis for 1.5 year) Monoclonal Gammopathy Congestive heart failure (EF: 30-35%) Prostate cancer (s/p prostatectomy in 1998) Hypertension Hypercholesterolemia

Laboratory Workup

Serum free light chains • Kappa: 706 mg/dL (normal: 0.33-1.94 mg/dL)

• Lambda: 3.2 mg/dL (normal: 0.57-2.63 mg/dL)

Bone marrow biopsy and flow cytometry

Plasma cell myeloma 10-20% kappa light chain restricted

Subcutaneous fat aspirate Negative for amyloid

Liver Biochemistries Alkaline phosphatase (ALP) 304 U/L (normal: 45-115 U/L)

ALP: liver isoenzyme 265 IU/L (normal: 16.2-70.2 IU/L)

Aspartate transaminase 51 U/L (normal: 8-48 U/L)

Alanine transaminase 42 U/L (normal: 7-55 U/L)

Direct/total bilirubin 0.1/0.6 mg/dL (normal: 0.0-0.3/≤1.2 mg/dL)

Negative serology Viral hepatitis

ANA, AMA, ASMA

Normal alpha-1 antitrypsin levels and phenotype (MM)

HISTOLOGIC FINDINGS

Low power view

Portal tracts

Acinar parenchyma

PAS-D

PAS-D PAS-D: normal

Trichrome Trichrome: normal

Iron

Differential Diagnosis

Diabetic Hepatosclerosis

Steatohepatitis

Venous Outflow Impairment

Amyloidosis

Col

lage

n

Differential Diagnosis: Diabetic Hepatosclerosis

H&E Trichrome

Differential Diagnosis: Steatohepatitis

H&E Trichrome

Differential Diagnosis: Venous Outflow Impairment

H&E Trichrome

Differential Diagnosis: Amyloidosis

Portal Linear

Globular

Differential Diagnosis: Amyloidosis

Congo Red

Differential Diagnosis Diabetic Hepatosclerosis

Steatohepatitis

Venous outflow impairment

Amyloidosis Special studies helpful to further investigate diagnosis: IHC

EM

MS

SPECIAL STUDIES

Congo Red Stain

Immunohistochemistry

Kappa light chain Lambda light chain

Electron Microscopy

Mass Spectrometry Powerful method of substance identification and quantification, by accurate

determination of its molecular mass

Identifies ionized molecules by measuring their m/z ratio

Vrana, Game, Madden et al. Blood. 2009 Dec 3;114(24):4957-9

Proteomics methods using MS have emerged as a useful method in protein identification in FFPE tissue

Amyloid identification/typing

Mass Spectrometry: Proteomics in FFPE Tissue

Proteome Software Inc.

Mass Spectrometry: Bioinformatics

Three distinct statistical algorithms used to identify proteins from MS data

Mascot Seaquest X-Tandem

Zenka, Johnson and Bergen, Exploring Proteomics Metadata using Spotfire and Companion User Interface (ASMS 2011)

Patient

Normal liver control0

20

40

60

80

100

120

11 kDa12 kDa

12 kDa25 kDa

36 kDa

Cluster of Iglambda chain C

regionsIg kappa chain C

region Cluster of Igkappa chain V-I

regionSerum amyloid P-

component Apolipoprotein E

Patient

Normal liver control

Molecular mass

Sig

nal

inte

nsi

ty

DIAGNOSIS Summary of findings: Perisinusoidal deposit

Congo Red: negative

EM: granular deposit in space of Disse

MS: kappa light chain deposit

Diagnosis: Light Chain Deposition Disease (LCDD)

involving the liver

DISCUSSION

LCDD Systemic disease characterized by: Clonal proliferation of plasma cells

Deposition of non-amyloid monoclonal immunoglobulin light chains in tissue

Occurs in 5% of multiple myeloma patients

Median age is 58 years

LCDD Tissue deposits cause organ

dysfunction kidney is the most frequently

involved organ

Laboratory diagnosis SPEP/UPEP

IFE

Immunoglobulin FLC

Bone marrow Bx/flow cytometry

Tissue biopsy

Nodular mesangial sclerosis with silver positive mesangial matrix

H&E Silver Jones

IF: Lambda IF: Kappa

LCDD: Liver Involvement

Occurs in 23% of cases Often accompanied by renal involvement

Liver involvement is most frequently asymptomatic

Variable clinical presentation

Abnormal liver biochemistries: Alkaline phosphatase most frequent

Portal hypertension is a frequent result

Microscopy Perisinusoidal deposits

PAS-D positive

Congo Red negative

Involvement by plasma cell neoplasm frequently absent

LCDD: Liver Pathology

Ultrastructure Granular deposit in

space of Disse

Perisinusoidal deposits spare portal tracts

LCDD: Liver Pathology

LCDD vs. Amyloidosis

Klabunde et al. Crystal structure of human transthyretin. Nature Structural & Molecular Biology 7, 312 - 321 (2000)

Protein deposits differ between the 2 entities: LCDD: light chains are unaltered

Amyloidosis (AL): misfolded proteins (beta-pleated sheet formation) Unique tinctorial properties

Association with universal amyloid protein

LCDD

Amyloid

LCDD vs. Amyloidosis: Ultrastructure

LCDD vs. Amyloidosis Systemic Amyloidosis LCDD

Plasma cell neoplasm Present (AL type) Present

Deposit location Variable perisinusoidal

Deposit appearance Variable Linear

Congo Red Positive Negative

PAS-D Negative or weak Positive

EM of deposits Randomly oriented fibrils Granular: space of Disse

MS • Monoclonal light chains (AL type) • Universal amyloid proteins

• Apolipoprotein E • SAP

• Monoclonal light chains • Low levels of universal

amyloid proteins

FOLLOW-UP

FOLLOW-UP Kidney biopsy: Kappa-light chain deposition disease

Liver involvement by LCDD initiation of treatment by Cyclophosphamide, Bortezomib and Dexamethasone

Pleural effusions Resolved by treatment with thoracocentesis

CHF Patient was diagnosed with dilated cardiomyopathy:

medical management with good control

FOLLOW-UP

0

100

200

300

400

500

600

0 2 4 6 8

Serum kappa-FLC

Serum kappa-FLC

0

20

40

60

80

100

120

140

160

0 2 4 6 8

Kappa/lambda FLC ratio

Kappa/lambdaFLC ratio

0

50

100

150

200

250

300

350

0 2 4 6 8

Alkaline phosphatase

Alkalinephosphatase

months

months

months

Conclusion LCDD is a rare but important entity to consider in the

differential diagnosis of amyloid-like deposits in the liver

LCDD has a characteristic perisinusoidal deposition pattern

The H&E histology of LCDD can be very subtle PAS-D can be helpful

Special studies can differentiate LCDD from amyloidosis: Congo Red EM MS

THANK YOU!

Questions/Comments?