Amyloid a in Systemic Amyloidosis Associated with Cancer1

[CANCER RESEARCH 42. 1600-1603, April 1982] 0008-5472/82/0042-OOOOS02.00 Amyloid A in Systemic Amyloidosis Associated with Cancer1

Gunnar Husby,2 Gudmund Marhaug, and Knut Sletten

Department of Rheumatology, Institute of Clinical Medicine, University of Tromsv, 9000 Troms0, Norway Â¡G.H.,G.M.], and Institute of Biochemistry, University of Oslo, Oslo, Norway [K.S.]

ABSTRACT Systemic amyloidosis is quite frequently associated with malignant neoplastic disorders, and immunocyte dyscrasias Amyloid fibrils from two cases of cancer-associated, sys account for the majority of such cases (30, 32). Hodgkin's temic amyloidosis with renal cell carcinoma and mesothelioma disease and renal cell carcinoma are other cancers sometimes as the respective underlying disorders were studied. The Â¡m- associated with systemic amyloidosis with a reported preva munochemical studies suggested strongly that amyloid A com lence of 4 and 3.2%, respectively (2), while solid neoplasms prised a principal fibril component in both cases of cancer- other than renal cell carcinomas are only sporadically found in associated amyloidosis. This was definitively proven by amino association with amyloidosis. acid sequence analyses, which revealed structural homology Whereas amyloid associated with immunocyte dyscrasias is between a purified subcomponent of the amyloid fibrils from of the immunoglobulin class (9) and amyloid reactive to Hodg both of the two cases of cancer-associated amyloidosis and kin's disease is of the AA class (18) corresponding to that previously sequenced amyloid A proteins. The chemical com associated with a variety of long-standing inflammations (27), position of the amyloid fibrils from systemic amyloidosis asso the chemical nature of amyloid fibrils associated with other ciated with cancer thus corresponded to that seen in amyloi dosis reactive to inflammatory diseases and Hodgkin's disease. cancers (i.e., solid tumors) has not been established (9). It was, therefore, believed to be of interest to investigate the structure Amyloid proteins of immunoglobulin light chain type, which are of the amyloid fibrils in 2 cases of cancer-associated systemic found associated with myelomatosis, macroglobulinemia, and amyloidosis, one with renal cell carcinoma and the other with idiopathic (primary) amyloidosis, were not found in the two mesothelioma as the underlying disorder. amyloid preparations. Renal cell carcinoma appears to be an effective stimulator of amyloid formation, while only one case MATERIALS AND METHODS of amyloidosis associated with mesothelioma has been re ported previously. Source of Amyloid Fibrils. Case 1, E. L., was a 53-year-old female, who for 2 years had felt tired, lost weight, and had periods of fever. At examination, a large tumor was felt Â¡nthe left side of the abdomen and INTRODUCTION the liver was enlarged. The patient had an elevated sedimentation rate, hematuria, and proteinuria. At laparotomy, a large tumor of the left The amyloid fibrils appear to be the unique and principal kidney, adherent to the colon, spleen, and pancreas, was removed. component of all forms of amyloid substance regardless of Histological examination of the tumor revealed a renal carcinoma made clinical type of amyloidosis (5). The fibrils are made up of up by clear and eosinophilic cells with a compact growth pattern and protein, and recent investigations have made it possible to extensive necrosis. Amyloid was found mainly in the vascular frame establish a chemical classification of amyloid based on the work of the tumor. Biopsies from the liver and rectum showed amyloi structural properties of the different amyloid fibril proteins and dosis. Postoperatively, she got an infected fistula from the colon to the to correlate the chemical classes of amyloid to various clinical left flank, and she died 3 months after the operation. Extensive amy types of amyloidosis (13). Homogeneous immunoglobulin light loidosis of the liver, spleen, and the right kidney was found at autopsy. No tumor mÃ©tastases were detected. She had not suffered any rheu chains or differently sized aminoterminal fragments thereof, AL3 (for nomenclature of amyloid, see Ref. 10), proteins com matic, infectious, or other malignant disease possibly underlying her systemic amyloidosis. It was concluded, therefore, that the amyloid prise a major component of the fibrils in idiopathic (primary) was reactive to renal carcinoma. Tissue from the right kidney was systemic amyloidosis and amyloidosis associated with immu- selected for extraction of amyloid. nocyte dyscrasias (9, 11) whereas AA plays a similar role in Case 2, B. K., was a 15-year-old male, who had been observed for cases of reactive (secondary) systemic amyloidosis (3, 13). A 1 year because of anemia, elevated erythrocyte sedimentation rate, serum protein, SAA, is larger but otherwise identical to AA and and increasing hepatomegaly. A needle biopsy from the liver showed is thought to be its precursor (for references, see 20). In massive amyloidosis. Except for occasional episodes of allergic rhinitis addition, a calcitonin-like protein, presumably a product of the without infectious complications, the young patient had been previously healthy, and no disease possibly underlying the patient's amyloidosis malignant cells, has been shown to be a component of the could be found. The patient was, therefore, diagnosed as having amyloid found locally in medullary carcinomas of the thyroid primary (idiopathic) amyloidosis. The following year, the patient devel (28). Also, some other tumors contain local amyloid deposits oped nephrosis, severe anemia, diarrhea, nausea, gastrointestinal (19), but the chemical nature of such deposits is not known. bleedings, and increasing hepatomegaly. He died after 2 years due to 1This work was supported by The Norwegian Research Council for Science renal failure and hemorrhagic diathesis. At autopsy, massive amyloi and the Humanities and the Norwegian Women's Public Health Association. dosis was found Â¡nthe liver (5620 g), spleen (450 g), retroperitoneal 1 To whom requests for reprints should be addressed, at Department of lymph nodes, kidneys, adrenals, intestine, and blood vessels. The Rheumatology, Institute of Clinical Medicine, University of Tromsa, Troms0, clinical pattern of amyloidosis was consistent with that of the reactive Norway. 3 The abbreviations used are: AL, amyloid light chain; AA, amyloid A; SAA, form of the disease. The autopsy findings also included a retroperito serum amyloid A; DAM, denatured amyloid fibrils. neal tumor, located close to but without direct connection with the Received September 11, 1981 ; accepted January 7, 1982. pancreas. The tumor was oval, soft, necrotic, and measured 8x4 cm.

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The microscopic appearance was consistent with that of a mesotheli- 0.8- B oma, which showed a monomorphic epithelial papillary histology. Amy M> AMYLOID E.L. loid was not present in the malignant tissue, except for small deposits SEPHADEX G-100 in capsular vessel walls. No other location of malignant tissue was i0'6" detected, and it was concluded that the tumor represented the primary cancer. The diagnosis was confirmed by histological reexamination of the tumor by an independent pathologist. The tumor was also examined S 0.4- by the Armed Forces Institute of Pathology and by the Canadian Tumor CM AA Registry without any definitive diagnosis being made. However, both agreed that mesothelioma was a probable diagnosis. The generalized 0.2- amyloidosis was thought to be reactive to the tumor, since no history or signs of concomitant infectious or inflammatory disease was found. It was believed improbable that the previous episodes of allergic rhinitis could initiate the formation of systemic amyloid. It was noted that the 20 40 60 80 100 regional lymph nodes were massively involved by amyloid. Liver tissue was used for extraction of amyloid. ELUTION VOLUME (ml) Extraction and Purification of Amyloid Fibril Proteins. The amyloi- Chart 1. A, gel filtration profile of amyloid E. L. treated with 6 M guanidine, dotic tissues were cut into small pieces and subjected to extraction of 0.05 M dithiothreitol. The retarded protein peak AA eluted corresponding to a molecular weight of 8500. B, sodium dodecyl sulfate-polyacrylamide gel electro amyloid fibrils with water after repeated washings of homogenized phoresis of material eluted in the protein peak AA (A). The mobility of the 2 bands tissue with 0.9% NaCI solution (23). The fibril-containing water super- corresponds to molecular weights of 8000 (band near origin at the top) and natants were lyophilized, treated with 6 M guanidine and a reducing 9000, respectively. agent, 0.05 M dithiothreitol, plus 1.0 mw EDTA, and thereafter sub jected to gel filtration on Sephadex G-100 under dissociating condi Table 1 Partial NH2-terminal amino acid sequence of cancer-associated amyloids E. L. tions as described (12, 16). Selected protein fractions eluted from the and B. K. Sephadex G-100 column were used for amino acid sequence studies after gel filtration on a Sephadex G-25 fine column (16). Electrophoresis. The method for sodium dodecyl sulfate-polyacryl- E.L.B. Ser_ Gly_ K.T.H."1Arg"-Ser"-Phea-5Phe _-Phe_-Leu _-Glu-10Ala_- amide gel electrophoresis has been described by Swank and Munkres (31). Approximately 50% of the polypeptide started with arginine, 40% started Immunological Studies. Double diffusion in 1% agarose gel was with serine, and 10% started with phenylalanine in both E. L. and B. K. used for immunological characterization of crude DAM and purified AA from amyloid associated with juvenile rheumatoid arthritis, reported amyloid proteins obtained by gel filtration (15, 16). In addition to DAM previously by Sletten and Husby (23). and protein fractions from amyloids E. L. and B. K., AA, SAA, and various amyloid proteins of AL type were used as controls (15, 20). Immunological Studies. The crude DAM E. L. and B. K. Antisera to these proteins were also used in the immunodiffusion test reacted with antisera to AA and SAA. The reactions were system (15). Rabbit antibodies to human immunoglobulin K- and A-light identical to each other and to the respective proteins used for chains (Bence-Jones proteins) were purchased from DAKO-immuno- immunization but not to any of the antisera to AL proteins or to globulins a/s, Copenhagen, Denmark. K-X Bence-Jones proteins. The same antigenic reactivity was Structural Studies. NH.-.-terminal amino acid sequence analysis was also achieved with the M, 8500 material obtained in the re performed by automated Edman degradation using the automatic se quence analyzer, JAS-47K, JEOL (27). tarded peak on gel filtration (Chart 1A) of both amyloids, while the void volume materials did not react with any of the antisera RESULTS used. The immunological studies thus suggested strongly that the protein fraction with a molecular weight of 8500 from The yields of water-extracted amyloids from E. L. (kidney) amyloid E. L. associated with renal cell carcinoma and the and B. K. (liver) were 0.9 and 1.0 g, respectively, of lyophylized corresponding protein material from amyloid B. K. associated fibril material per 20 g of each of the fresh tissues. The fibril with mesothelioma were AA or an antigenically related protein. preparations exhibited the typical green birefringence of amy Amino Acid Sequence Studies. The 10 NH2-terminal amino loid when stained with Congo red and examined microscopi acid residues of the low-molecular-weight protein fraction of cally under polarized light. amyloids E. L. and B. K. are shown in Table 1. The 2 sequences Gel Filtration Studies. The elution profiles obtained when were identical and corresponded to those of AA from systemic dissociated and reduced amyloid E. L. and B. K. were gel amyloidosis associated with chronic inflammation (3, 6, 16, filtered on Sephadex G-100 (Chart 1) were almost identical to 27), familial Mediterranean fever (18), and Hodgkin's disease each other and very similar to those of several reactive AA-type (18) sequenced previously. Thus, the amino acid sequence amyloids reported previously by us (14). In addition to a large study proved that AA was a principal component of the 2 protein peak eluted in the void volume (Chart 1A, V0), approx cancer-associated amyloids E. L. and B. K. Both sequences imately 45% of the protein material was eluted in a retarded (Table 1) showed some heterogeneity among the 3 NH2-ter- peak corresponding to a molecular weight of 8500, which is minal amino acid residues. This has also been observed in AA compatible with the size of known human AA proteins (13). The derived from amyloidosis associated with nonmalignant dis sodium dodecyl sulfate-polyacrylamide gel electrophoretic pat eases (6, 18, 21). terns of the retarded protein fraction of E. L. and B. K. were also identical (Chart 1ÃŸ)with 2 closely migrating protein bands DISCUSSION in the molecular weight range of 8000 to 9000. The 2 bands most probably reflected heterogeneity with respect to size in The results of the present study showed clearly that AA the C-terminal end of both proteins (21). comprised a principal fibril component in 2 cases of systemic

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Downloaded from cancerres.aacrjournals.org on September 27, 2021. © 1982 American Association for Cancer Research. G. Husby et al. amyloidosis associated with cancer, namely renal cell carci important for amyloid formation, since many cases of reactive noma and mesothelioma, although the histological diagnosis of amyloidosis associated with nonmetastatic tumors have been the latter tumor was not completely verified. This has been reported (29), and this was also the case with our 2 patients. suggested previously by us on the basis of immunological It is interesting, however, that high serum concentrations of studies, which revealed a close antigenic relationship between SAA have been found to be associated with the dissemination AA and the same 2 cases of cancer-associated amyloid (17), of cancer (24). However, factors other than high serum levels but a definite proof for this association has not been reported of SAA are indeed needed for the formation of reactive systemic before (9). AA is thus distributed widely in systemic amyloidosis amyloidosis (8, 13). The mechanisms by which SAA is con including cases associated with cancer. The other principal verted to AA and deposited as amyloid fibrils in the tissues are type of protein that makes up systemic amyloid fibrils, namely far from being understood. AL protein, has been found mostly in cases of idiopathic amyloidosis (which can be regarded as a form of immunocyte ACKNOWLEDGMENTS dyscrasia) (9, 13) and those associated with the monoclonal gammopathies, myelomatosis and macroglobulinemia. Even The authors wish to thank Drs. Fr0ydis Langmark and Helge Stalsberg for among such cases, AA-type amyloid has indeed been found providing amyloidotic tissues and for help with the histological diagnoses, Anita Skoge for typing the manuscript, and Kirsti Ranne for technical assistance. (17). However, the 2 cases reported here are certainly not enough to permit the conclusion that cancer-associated sys temic amyloidosis is always of the AA type. It can be mentioned REFERENCES that serum M-components are found frequently in patients with 1. Ashley, D. J. B. Primary tumours of coelonic surfaces. In: D. J. Ashley (ed.), nonreticular tumors (33), and Bence-Jones proteins, potential Evan's Histological Appearances of Tumours, pp. 650-658. New York: precursors of AL-type amyloid, have been found in the urine of Churchill Livingstone, 1978. patients with renal cell carcinoma (7). More studies are needed, 2. Azzopardi, J. G., and Lehner, T. Systemic amyloidosis and malignant dis ease. J. Clin. Pathol. (Lond.), 19: 539-548, 1966. therefore, to see if also the immunoglobulin (AL) type of sys 3. Benditi, E. P., Eriksen, N., Hermodson, M. A., and Ericsson, L. H. 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AA in Cancer-associated Amyloidosis

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Gunnar Husby, Gudmund Marhaug and Knut Sletten

Cancer Res 1982;42:1600-1603.

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