Some interpretational problems associated with the myofibroblast, which affect how this cell is identified, are discussed. Questions addressed include distinguishing between "external" lamina ("basement membrane") and the fibronectin fibril of the fibronexus; the nature of stress fibers (bundles of smooth-muscle myofilaments with focal densities); the utility of some of these features to distinguish between myofibroblastic and smooth-muscle cell surfaces; and cytoskeletal immunophenotype. The following points are emphasized. Myofibroblasts have a surface characterized by prominent fibronectin fibrils and fibronexus junctions, which are distinct from lamina ("basement membrane"). This can permit a distinction to be made between smooth-muscle and myofibroblastic lesions and tumors. Myofibroblasts are typically positive for vimentin and alpha-smooth-muscle actin, but desmin is not a useful discriminant between smooth-muscle and myofibroblastic lesions. The main features for defining the myofibroblast are abundant rough endoplasmic reticulum; modestly developed peripheral myofilaments with focal densities (stress fibers); fibronexus junctions; vimentin and smooth-muscle actin immunostaining. Other features include a Golgi apparatus and collagen secretion granules, gap junctions, and actin-associated nondesmosomal junctions. Illustrations of the usefulness of these criteria in the diagnosis of soft-tissue lesions (myofibrosarcoma, so-called myofibroblastoma) are given.

The myofibroblast: an assessment of controversial issues and a definition useful in diagnosis and research.

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, homogenous 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 α-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. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:57-65)

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

This brief review details the structure, nature, and distribution of the fibronexus, and discusses its significance for myofibroblastic differentiation and tumor diagnosis. The fibronexus is a cell surface specialization consisting of intracellular actin filaments and extracellular fibronectin filaments associated with subplasmalemmal plaque material. The fibronexus represents an intercellular junction between myofibroblasts, but in particular is a device for providing contact between myofibroblasts and matrix that mediates continuity between intracellular contractile filaments and extracellular matrix proteins. Immunoelectron microscopy in particular has shown that the intracellular filaments contain actin. The extracellular filaments contain fibronectin and collectively form the fibronectin fibril. The plaque probably contains such proteins as vinculin, talin, alpha-actinin, and integrin. Under appropriate biologic development and fixation conditions, the fibronectin fibril of the fibronexus is characterized by and distinguished from lamina by enhanced density, a rigid appearance, failure to adhere closely to the contours of the cell surface (except focally near the plaque material), and a longitudinally filamentous substructure. Confirmation of the presence of a fibronectin fibril may be obtained by the finding of intense cell surface staining with an antifibronectin antibody. Problems in identifying the fibronexus may be encountered, however, due to poor development and fixation, in which case the filamentous substructure may be inapparent. The fibronexus is such a typical feature of and is often so conspicuous in myofibroblasts that it can be regarded as perhaps essential for the interpretation of myofibroblastic differentiation. Structures with a similar appearance have been documented in fundamentally nonmyofibroblastic cells; these include aortic and scleral spur smooth muscle cells and endothelium. Uncertainties remain in the protein composition of the fibronexus, the nature of its contact with the matrix, and its relationship to similar structures seen in nonmyofibroblastic cells. Immunoelectron microscopy provides a potential means of clarifying some of these questions.

Brief Review of the Fibronexus and Its Significance for Myofibroblastic Differentiation and Tumor Diagnosis

Spindle cell tumours of the breast are uncommon and often present diagnostic challenges The most important is the sarcomatoid/metaplastic carcinoma, which has monophasic and biphasic variants Each of these groups presents special diagnostic difficulties In the monophasic variant the mesenchymal component predominates and the epithelial element forms a minor component often detected only after immunohistochemical study The spindle cell areas may be bland and therefore under-diagnosed as nodular fasciitis or fibromatosis Alternatively they may be highly malignant with a pattern that is misinterpreted as primary sarcoma of the breast In the biphasic variant, the difficulty is in distinguishing between sarcomatoid carcinoma, myoepithelial carcinoma or malignant phyllodes tumour Other spindle cell lesions of the breast include the various myofibroblastic tumours, the spindle cell variant of adenomyoepithelioma, the varied primary breast sarcomas, metastatic tumours with spindle cell morphology and, finally, the very rare follicular dendritic cell tumour A simple practical approach to the diagnosis of spindle cell lesions is presented to help the general surgical pathologist to compile a differential diagnosis and to arrive at the correct conclusion

Spindle cell tumours of the breast: practical approach to diagnosis

Myofibrosarcomas are malignant tumours of myofibroblasts, which have been recognised for many years, but have become clearly defined only recently. They are low- or high-grade sarcomas that arise in soft tissue or bone in adults or children. Low-grade myofibrosarcomas are infiltrative tumours, usually in deep soft tissue, with a predilection for the head and neck region, which display a range of microscopic appearances from fasciitis-like to fibrosarcoma-like; all cases at least focally display nuclear pleomorphism. They express smooth-muscle actin and calponin, and some express desmin, but most lack h-caldesmon. Low-grade myofibrosarcomas can recur but rarely metastasise. Their differential diagnosis is from benign myofibroblastic proliferations, such as fasciitis and fibromatosis, as well as from fibrosarcoma and leiomyosarcoma. Pleomorphic myofibrosarcomas are high-grade pleomorphic sarcomas (malignant fibrous histiocytoma), which show ultrastructural evidence of myofibroblastic differentiation. They closely resemble malignant fibrous histiocytoma clinically and morphologically, but are more frequently actin positive. This article describes the low- and high-grade variants of myofibrosarcoma and other malignant tumours with myofibroblastic differentiation.

Myofibrosarcoma

A low grade soft tissue sarcoma from the naso-labial fold and designated as myofibrosarcoma (sarcoma of myofibroblasts) is described using standard light microscopy techniques, immunohistochemistry and electron microscopy. Pink fibrillated cytoplasm, regarded as one of the typical histological features of leiomyosarcoma, was not obvious but immunostaining for alpha-smooth muscle actin was positive suggesting smooth muscle differentiation. By electron microscopy, tumour cells contained abundant rough endoplasmic reticulum cisternae and a large Golgi body; there were modest but numerous bundles of fine filaments with focal densities. A conventional lamina was lacking but the cell surface was characterised by fibronexus junctions in which there was a conspicuous extracellular, fibronectin-containing fibril, apparently mediating contact between cell and matrix. The tumour cells therefore showed myofibroblastic differentiation. The cell surfaces showed strong immunoreactivity with an anti-fibronectin antibody. Myofibrosarcoma is not a widely recognised entity and this case is only the 7th example to be documented in detail by means of both immunohistochemistry and ultrastructure. The combination of electron microscopy for detecting the fibronexus junction and immunostaining for fibronectin at the cell periphery is suggested as potentially useful for distinguishing myofibrosarcoma from leiomyosarcoma.

L Christensen

Papers

Myofibrosarcoma of subcutaneous soft tissue of the cheek.