Recurrent adult myofibromatosis. A case report

Spontaneous remission of solitary-type infantile myofibromatosis

Infantile myofibromatosis is a rare fibrous tumor of infancy. The cutaneous solitary type has typically an excellent prognosis. However, histologically, it is important to rule out leiomyosarcoma, which has a poor prognosis. The low frequency of mitosis was definitive for a diagnosis of infantile myofibromatosis. We present a cutaneous solitary-type case of infantile myofibromatosis. Following incisional biopsy, the tumor remitted spontaneously.

Aggressively recurrent infantile myofibroma of the axilla and shoulder girdle

Infantile myofibroma is the most common fibrous tumor of infancy, typically affecting neonates and children under 2 years of age. Though the multicentric variant portends a grave prognosis, solitary lesions have an excellent prognosis and frequently undergo spontaneous regression. Surgical excision of solitary lesions is usually curative. In this report, we describe a pediatric patient with an unusually aggressive solitary myofibroma of the axilla who ultimately required a forequarter amputation as a lifesaving measure following multiple tumor recurrences and progressive tumor growth. The clinical course, radiographic findings, histology, and management rationale are presented.

An unusual myofibroblastic proliferation of the pinna

INTRODUCTION

Myofibrosis of the ear is rare. Myofibromas are mesenchymal tumours which usually present in infancy but have been reported sporadically in adults.

OBJECTIVE

To present a rare case of trauma as a cause of pinnal myofibrosis.

DESIGN AND METHOD

Case report. A 29-year-old soldier suffered repeated trauma from helmet wear and sports, and presented to our clinic with an exquisitely painful lump in the anti-helix of the pinna.

RESULTS

The lump was excised uneventfully. Pathology revealed a reactive myofibroblastic proliferation which, given the history of trauma, raised the possibility of a florid cellular repair process. The main differential diagnosis was myofibroma. Immunohistochemistry was used to exclude other possible causes.

CONCLUSION

No similar case has previously been reported. The aetiology of myofibroma is unclear, but repeated trauma may be a trigger. Histological and immunohistochemical analysis are recommended when the diagnosis is ambivalent.

A partially regressed, atrophic plaque on a 17-year-old girl: an unusual presentation of myofibromatosis

Solitary cutaneous myofibromas have been reported in patients of all ages. Infantile and adult forms are distinguished by age of onset, location of lesions, and the potential for infantile myofibromas to regress. We report a case of a 17-year-old girl with a solitary myofibroma on the right leg that presented as a partially regressed, atrophic plaque with multiple surrounding papules. Unusual features of this case include the tumor size, simultaneous regression and proliferation, patient age, and gender.

Solitary infantile myofibroma compromising the airway

Infantile myofibromatosis is an uncommon and benign condition presenting in the neonatal period. It is self-limiting disease that may present as a localised or generalised process. Various examples of this entity have been reported in the literature. This report describes a neonate with a rapidly growing oropharyngeal lesion obstructing the airway that had the typical histological features of an infantile myofibroma. This case report highlights that a solitary myofibroma may be incredibly extensive making complete excision impossible and can be particularly challenging to manage in terms of airway stabilisation.

Myofibroma of the Cheek: A Case Report

Myofibromas are benign mesenchymal tumors that are commonly found in the dermis and subcutaneous tissues of the head and neck. Although most lesions are recognized daring infancy and early childhood, several cases have been reported in older children and adults. We describe the case of a 9-year-old girl who presented with a solitary nodule in the left cheek and a history of minor trauma. Preoperative imaging detected the presence of a subcutaneous soft-tissue mass consistent with a soft-tissue neoplasm rather than a hematoma. Analysis of fine-needle aspiration material was nondiagnostic. Incisional biopsy revealed that the lesion was a myofibroma.

Intravascular myopericytoma

BACKGROUND

Myopericytoma is a benign tumor composed of cells that show apparent differentiation towards putative perivascular myoid cells called myopericytes. It arises most commonly in the dermis or subcutaneous tissue of the extremities in adults.

METHODS

We describe a myopericytoma that was unusual in its intravascular location.

RESULTS

A 54-year-old man presented with a 10-year history of a painful slowly growing 1.5-cm nodule in the subcutaneous tissue of the thigh. Histologic examination of the excised lesion showed that is was entirely contained within the lumen of a vein. It was composed of a proliferation of myoid-appearing spindle cells, which were arranged in a striking concentric pattern around numerous blood vessels, in a manner that accentuated the vessel walls. This pattern is characteristic of myopericytoma. In some areas, fascicles of spindle cells, embedded in a myxoid stroma, bulged into the lumina of lesional vessels, reminiscent of myofibroma/myofibromatosis. Lesional spindle cells were diffusely positive for smooth muscle actin, focally positive for CD34 and were negative for desmin, cytokeratin, S100 protein, HMB-45 and CD31.

CONCLUSION

This case illustrates that myopericytoma can be entirely intravascular in its location.

Adult acral cutaneous myofibromas in a patient with generalized morphea

Myofibroma is the term for a group of solitary or generalized soft tissue tumors that may be located in the skin or within skeletal muscle, bone, and viscera. These tumors occur most commonly in children. However, examples of myofibroma have been reported in adults, in whom they usually present as solitary lesions of the head and neck, trunk, and extremities. "Cutaneous nodules" have been reported in both localized and systemic scleroderma, but to our knowledge, there are no specific reports of myofibromas developing in this patient population. We report a case of acral myofibromas in a patient with generalized cutaneous morphea. This occurrence is of interest in view of the possible role of myofibroblasts in the pathogenesis of scleroderma.

Cutaneous smooth muscle neoplasms: clinical features, histologic findings, and treatment options

Cutaneous smooth muscle is present in 3 separate locations: arrector pili muscles, blood vessel walls, and genital/areolar skin. Benign or malignant smooth muscle neoplasms may arise from each of these locations. This review discusses the pathogenesis, clinical manifestations, histologic findings, prognosis, treatment options, and controversial areas of cutaneous smooth muscle neoplasms. ( J Am Acad Dermatol 2002;46:477-90.)

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be able to discuss the pathogenesis, clinical manifestations, histologic findings, prognosis, and treatment options of cutaneous smooth muscle neoplasms.

Myofibromas and myofibromatosis of the oral region: A clinicopathologic analysis of 79 cases

The clinicopathologic features of 79 myofibromas or myofibromatoses of the oral and maxillofacial region were studied. The case studies were taken from the files of the Armed Forces Institute of Pathology. The tumors affected 44 males and 33 females (gender was unknown in 2 cases). The patients' ages at diagnosis ranged from birth to 84 years, with mean and median ages of 26.6 and 22 years, respectively. Four patients had infantile myofibromatosis; 2 had extraoral bone lesions and 2 had multiple subcutaneous tumors. In descending order, tumors involved the mandible, tongue, lips, cheek or buccal area, maxilla or palate, pterygomandibular raphae, floor of mouth, and submandibular gland. One third of the tumors affected the bones of the jaws; 12 were central and 15 were cortical or periosteal. All medullary tumors occurred in patients under age 18. On gross examination, the lesions were firm, homogeneous or whorled, white-grey fibrous masses that ranged in size from 0.5 to 5.0 cm. Microscopically, all tumors demonstrated a pattern of nodules or bundles of spindle cells separated by areas of greater cellularity and crescent-shaped vascular spaces. Distinct hemangiopericytoma-like areas were present in 22 cases. Despite apparent circumscription, the tumors commonly infiltrated and entrapped adjacent muscle, nerve, or salivary tissue. Immunohistochemically, 37 of 37 and 39 of 39 tumors stained positively for alpha-smooth muscle actin and muscle-specific actin, respectively, with the former eliciting a more intense reaction. Eight of 8 tumors were weakly positive for CD68, and one case stained focally with S-100 protein. No desmin staining was present in 36 tumors examined. Diagnostic interpretations by the pathologists seeking consultation were malignant or aggressive tumors in 31 cases and other benign conditions in 26. Nine were interpreted as myofibromatosis and 13 offered no interpretation. Thirty-two patients were alive and free of tumor an average of 42 months after initial diagnosis. Four patients had one recurrence each, and 2 had lesions recur twice. Myofibromas are relatively common soft tissue tumors of the maxillofacial region, which have been misinterpreted as malignant or aggressive lesions.

Solitary adult myofibroma of the pinna

Solitary myofibroma is a recently described benign neoplasm of the skin or superficial soft tissue and it represents the adult counterpart of infantile myofibromatosis. This new clinicopathological entity is being recognized increasingly. A case of solitary myofibroma occurring in the pinna of a 50-year-old woman is presented. Such a lesion occurring in the pinna of an adult has not been reported in the literature.

Myofibromatosis in adults, glomangiopericytoma, and myopericytoma: a spectrum of tumors showing perivascular myoid differentiation

The clinicopathologic features of 24 tumors showing perivascular myoid differentiation are described. These included tumors with histologic features of "infantile-type" myofibromatosis occurring in adult patients (8 cases), tumors with composite features of "hemangiopericytoma" and glomus tumor (9 cases), and tumors with a distinctive concentric perivascular proliferation of spindle cells (7 cases). Evidence of morphologic overlap among these groups suggests they are closely related neoplasms that form a single spectrum. Age of patients with lesions resembling infantile-type myofibromatosis ranged from 23 to 67 years (median, 37 years). Clinicopathologic manifestations of this disease included multicentricity (4 cases), local recurrence (3 cases), persistence of congenital lesions into adulthood (4 cases), and tumors that were multifocal within the confines of one anatomic region (7 cases). Histologically, all cases showed a biphasic pattern that consisted of fascicles of spindle cells with abundant eosinophilic cytoplasm that resembled smooth muscle, in addition to a population of more primitive spindled cells associated with a hemangiopericytomalike vascular pattern. Six cases showed reversal of the typical zonation seen in pediatric cases in that the primitive component surrounded the more mature fascicular areas. Also described are nine tumors with features that are intermediate between glomus tumor and hemangiopericytoma, which we have designated glomangiopericytoma. These tumors are characterized by prominent branching vessels lined by a single row of endothelial cells surrounded by epithelioid cells with a glomoid appearance. In other areas, the tumors showed typical hemangiopericytomatous foci similar to those in the myofibromatosis cases. The principal points of distinction were a lack of myoid nodules and an absence of small primitive cells with basophilic cytoplasm. Ages of these patients ranged from 17 to 78 years (median, 35 years). All tumors were located in the subcutaneous tissue and the superficial soft tissue of the extremities. Recurrence developed in one of six patients with follow-up information. The recurrent tumor had features of angiomatoid malignant fibrous histiocytoma. Finally, we describe a subset of tumors characterized by concentric periluminal proliferation of bland, round to ovoid cells, which we have designated as myopericytoma. Patient age ranged from 10 to 66 years (median, 40 years). All were located in subcutaneous and superficial soft tissue of distal extremities. One patient had two recurrences in 3 years after initial excision. Our study suggests that these three lesional groups comprise a histologic continuum of tumors that share clinical similarities and that, perhaps, are designated more appropriately as perivascular myomas. The relationship of this family of tumors to so-called hemangiopericytoma is discussed.

Cutaneous adult myofibroma: a vascular neoplasm

Infantile myofibromatosis is a distinctive type of fibromatosis that usually develops during the immediate perinatal period. There are variants with solitary and multiple tumors. Lesions confined to the skin, soft tissue, and bone carry a good prognosis, showing spontaneous regression. The prognosis, however, is much less favorable when visceral lesions are present and the outcome may be fatal. Only recently it became obvious that there is an adult counterpart of infantile myofibromatosis, characterized by solitary lesions that have a predilection for involve the dermis and show no tendency to regression, although they have an entirely benign biological behavior. These lesions have been named cutaneous myofibroma or solitary myofibroma of adults. We have studied the clinical, histopathological and immunohistochemical characteristics of 53 examples of cutaneous adult myofibroma. In addition, 2 cases were examined ultrastructurally. The patients were mostly adults with ages ranging from 6-83 years. The lesions presented as solitary, usually painless nodules of variable duration on the skin, usually located on the extremities. Histopathologically, four patterns were identified: nodular or cellular type, multinodular or biphasic type, leiomyoma-like or fascicular type, and vascular type. A correlation between the histopathologic pattern and the lesional age was observed: vascular type of cutaneous adult myofibroma in early lesions, nodular and multinodular lesions in fully developed lesions, and leiomyoma-like or fascicular type in late lesions. Immunohistochemically, the spindle cells were desmin negative, but expressed immunoreactivity for vimentin, pan-smooth muscle actin, and alpha-smooth muscle actin. Ultrastructurally, neoplastic cells showed characteristics of undifferentiated mesenchymal cells with features of fibroblasts, myofibroblasts and pericytes. Primitive vascular formations were seen in the form of irregular clefts between adjoining cells. We conclude that cutaneous adult myofibroma is a little-known benign vascular neoplasm probably derived from myopericytes.

Solitary cutaneous myofibromas in adults: report of six cases and discussion of differential diagnosis

Six solitary, dermal or subcutaneous lesions occurring in adult patients are presented. These masses had a circumscribed, lobulated configuration; they were composed of fusiform and epithelioid cells that lacked atypical nuclear features. The pattern of growth featured fascicles and nests, a myxofibrous stroma, and prominent blood vessels with a focally "hemangiopericytoid" appearance. Immunohistochemical analyses showed uniform reactivity for vimentin and alpha isoform-actin, with negativity for desmin and neural determinants. The overall appearance of the lesions was similar to that of "infantile myofibromatosis," and corresponded to previous descriptions of "solitary myofibroma(tosis)" in adults. Immunophenotypic and ultrastructural support exists for a proposed myofibroblastic nature for such proliferations. Differential diagnostic considerations include neurothekeomas, plexiform fibrous histiocytomas, nodular fasciitis, cutaneous inflammatory pseudotumors, dermatomyofibromas, leiomyomas, and other forms of fibromatosis affecting the skin and superficial soft tissues.

Solitary cutaneous myofibroma of the glans penis

In the present report, we describe a cutaneous myofibroma with a monophasic pattern. The patient was a 12-year-old white boy with an asymptomatic yellow nodule on his glans penis for about 2 1/2 months. The nodular pattern of growth is distinctive: nests of plump spindle cells with a tendency toward interstitial hyalinization within the dermis. Confirmation of the myofibroblastic nature of the proliferation was obtained by histochemical and immunohistochemical studies. The tumor cells showed immunoreactivities for vimentin, alpha-smooth-muscle actin, and collagen type IV but did not stain for desmin. To the best of our knowledge, this is the first case of cutaneous myofibroma to occur on the glans penis. This tumor should be included in the differential diagnosis of mesenchymal neoplasms of the penis.

Myofibromas of the oral cavity

Solitary infantile myofibromatosis or myofibroma of the oral cavity is an uncommon condition with only 32 reported cases in the English-language literature. This article presents four additional cases of these solitary myofibroblastic lesions. In addition, the clinical and histologic features of this uncommon spindle cell neoplasm have been reviewed. The similarity in both the clinical and histopathologic features of the "adult" and "infantile" lesions support the proposal that myofibroma is a more accurate and acceptable term for these solitary myofibroblastic lesions of the oral cavity.

Use of monoclonal antibody 1H1, anticortactin, to distinguish normal and neoplastic smooth muscle cells: comparison with anti-alpha-smooth muscle actin and antimuscle-specific actin

In preliminary experiments, we found that 1H1, a monoclonal antibody directed against the v-src substrate cortactin, reacts with smooth muscle, myoepithelium, myofibroblasts, and macrophages in formaldehyde-fixed human tissues. To evaluate the use of this antibody as a diagnostic reagent, we tested the immunohistochemical distribution of cortactin in 61 mesenchymal neoplasms, 11 neuroectodermal neoplasms, and eight embryonal epithelial neoplasms. The results were compared with those obtained using antibodies against alpha-smooth muscle actin and muscle-specific actin on a similar set of tissues. With the exception of positive staining in rhabdomyosarcoma, in this series only tumors with smooth muscle differentiation appeared to contain cortactin (16 of 19 leiomyosarcomas, one infantile fibrosarcoma, one malignant fibrous histiocytoma). Immunoelectron microscopy localized cortactin to the actin-associated dense bodies of the microfilament network. We conclude that cortactin may be a useful adjunct to alpha-smooth muscle actin and muscle-specific actin as a marker for the study and diagnosis of smooth muscle neoplasms and related lesions.

Solitary myofibroma in adults: clinicopathological analysis of a series

Solitary myofibroma is a recently described, benign neoplasm of superficial soft tissue, which represents the adult counterpart of infantile myofibromatosis and is poorly recognized. Eleven new cases are presented herein. The patients were mostly adults with ages ranging from 13-64 years. They presented with a solitary, usually painless nodule of variable duration in the skin or oral cavity. Histologically, each lesion had a biphasic pattern with spindle cells forming fascicular or whorled areas and rounded, more primitive cells arranged around small vessels, forming haemangiopericytoma-like areas. The characteristic zonation of infantile myofibromatosis was often less marked in adult lesions and there was a haphazard arrangement of the fascicular and pericytic areas in some cases. Hyalinization, especially of the peripheral spindle-celled areas, was frequent. Immunohistochemically, the spindle cells were desmin negative but muscle actin (HHF-35 and IA4) positive. The rounded cells were both desmin and actin negative. Electronmicroscopy confirmed the myofibroblastic/fibroblastic nature of tumour cells in two cases. Although vascular invasion was seen in two cases, solitary adult-type myofibroma pursues a benign clinical course.