Download RHABDOMYOMA The benign tumor of striated muscle, or so

T H E AMERICAN JOURNAL OF CLINICAL PATHOLOGY
Vol. 40, No. 0
Copyright © 1968 by The Williams & Wilkins Co.
Printed in
U.S.A.
RHABDOMYOMA
REPORT OF CASE WITH ULTRASTRUCTURAL AND HISTOCHEMICAL STUDIES
BERNARD CZERNOBILSKY, M.D., JOHN L. CORNOG, JR., M.D., AND
HORATIO T. ENTERLINE, M.D.
Laboratories of Pathologic Anatomy and Department of Pathology (Neuropathology) of the Hospital of the
University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104
The benign tumor of striated muscle, or
so-called rhabdomyoma, is a rare entity.
The literature yields only 13 acceptable
cases, 2 ' 3 ' 5' 12' 15' ',6' n- 2 °. 21 ' ' 23 ' 26 ' 27 if one excludes the cardiac lesion bearing the same
name, and excludes as well a variety of
other tumors which have occasionally been
reported as rhabdomyomas. The present report deals with an additional case of a
rhabdomyoma upon which, for the first time,
histochemical enzyme reactions and ultrastructural studies were performed. These
studies have helped to clarify the relationship of rhabdomyoma to normal skeletal
muscle and to granular cell myoblastoma, as
well as to the cardiac rhabdomyoma.
R E P O R T O F CASE
R. S., a 39-year-old white man, noticed a
lump on the left side of the soft palate 6
years prior to admission to the Hospital of
the University of Pennsylvania. At that time
the mass was excised (presumably not completely) at another hospital. Five years later
the mass recurred and steadily increased in
size.
On his admission to the University hospital, significant physical findings were
limited to the area of the tumor which involved the soft palate and pharyngeal wall
on the left. The mucosa of this region was
raised but not ulcerated. Externally a 5- by
6-cm. mass was palpable at the angle of the
left mandible and submandibular space.
There was no palpable cervical lymphadenopathy and the trachea was in the midline.
Following a biopsy, resection of this mass
was performed.
Received July 15, 19C7.
The ultrastructural portion of this study was
supported by Research Grant NB-05772-03 of the
National Institutes of Health.
At operation it was noticed that most of
the tumor was retropharyngeal and multilobular. It extended as far as the jugular
foramen. The tumor was excised and the
patient was discharged in good condition.
The patient is living without recurrence 12
months after the operation.
Pathologic Features
Gross findings. The specimen consisted of
multiple brown lobulated pieces of tissue
weighing 95 Gm. in toto. Cross-sections
showed uniform yellow-brown fleshy tissue
with a few foci of necrosis (Fig. 1).
Microscopic findings. Sections (Figs. 2 to
4) revealed the tumor to be composed of
large round to oval cells with pale, pinkstaining, faintly granular cytoplasm. Many
cells contained large vacuoles. In a few cells
definite cross-striations were identified. Isolated cells contained collections of crystallike particles, haphazardly arranged. The
nuclei were uniform, round or oval, and
vesicular, with fairly prominent nucleoli,
and were usually centrally located. In a portion of the tumor close to an area of necrosis
the cells appeared smaller, with somewhat
more hyperchromatic nuclei. A few connective tissue septae with blood vessels traversed the tumor.
The slides from the first resection of the
lesion which was performed at another hospi
tal were reviewed and showed similar histo
logic features.
Materials and Methods
Tissue from the rhabdomyoma selected foi'
hematoxylin and eosin stain, McManus
periodic acid-Schiff (PAS) reaction, Gomori's
iron stain, oil red 0 , Mayer's mucicarmine,
crystal violet, a modified Snook's reticulum,
and Masson's trichrome stains was fixed in
10% neutral buffered formalin. The tissue
782
June 1968
RHABDOMYOMA
l''[G. 1. Gross appearance of cut surface of rhabdomyoma
selected for Bauer-Feulgen glycogen stain
was fixed in Carnoy's fluid. Zenker's solution
was used as a fixative for Mallory's phosphotungstic acid hematoxylin (PTAH). The
sections stained with PAS and Bauer-Feulgen glycogen stain were examined with and
without antecedent diastase digestion. The
oil red 0 stain was clone on frozen section
material; tissues prepared for the other stains
mentioned above were embedded in paraffin.
Histochemical studies were performed on
tissues obtained within 10 min. after
excision. Those selected for acid phosphatase, alkaline phosphatase, and esterase reactions were immediately placed at 4 C. in a
solution of calcium-formol. Adenosine triphosphatase (ATPase) and succinic dehydrogenase reactions were performed on
material freshly frozen in liquid nitrogen. All
the tissues prepared for histochemical reactions were cut in a cryostat at 6/J.
The acid phosphatase method used has
been reported by Evans and associates.6
The alkaline phosphatase determination was
by Tsou's modification of the acid phosphatase technic.26 Tsou's modification of Barrnett and Seligman's indigogenic method for
esterase1 was used. ATPase determination
was by Padykula and Herman's modification" of Gomori's method, and succinic
dehydrogenase determination was performed
as described by Nachlas and colleagues.17
In addition to tissue from the rhabdomyoma upon which all of the above named
histochemical studies were performed, acid
and alkaline phosphatases, esterase, ATPase,
and succinic dehydrogenase were also studied
in normal skeletal muscle. Tissue from a
granular cell myoblastoma was studied for
acid phosphatase and esterase activity.
Tissue from the rhabdomyoma for electron
microscopy was prepared as follows. Small
blocks of tissue away from areas of obvious
necrosis or hemorrhage were fixed for 2 to
2V2 hr. at 4 C. in 5 % glutaraldehyde in 0.2
M cacodylate buffer and then washed during
the next hour in three changes of 0.1 AI cacodylate buffer with 10% sucrose,24 also at 4 C.
Tissue was then postfixed in Millonig's fixative containing 1 % Os0 4 for 1 hr., dehydrated in graded alcohols and propylene
oxide, and embedded in English Araldite
(Ciba Company, Duxford, Cambridge, England). Sections stained with uranyl acetate13
and lead citrate22 were examined with' a
Siemens' Elmiskop I. Routine histologic examination was made of sections of the tumor
cut from paraffin-embedded tissue and
stained with hematoxylin and eosin. The
dimensions of ultrastructural features here
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CZEUNOBILSKY ET
Vol. 49
AL.
I n normal skeletal muscle there was no
acid or alkaline phosphatase activity. Esterase activity was weak in normal muscle and
in t h e rhabdomyoma. A T P a s e showed
marked activity in some fibers ( T y p e I I ) and
none or weak reaction in others (Type I ) .
Sections stained for succinic dehydrogenase
activity showed a well defined striated pattern with areas of strong (Type I) and weak
(Type I I ) activity. Granular cell myoblast o m a showed extremely intense acid phosphatase and somewhat less intense esterase
activity in the granular cells.
I t is of interest t h a t , despite the difficulty
of finding convincing cross-striations with
TABLE 1
SPECIAL STAINS IN RHABDOMYOMA
Results
Special Stains
FIG. 2. Photomicrograph of rhabdomyoma
showing large round to oval cells with scattered
vacuoles. Hematoxylin and eosin. X 125.
recorded represent the average of a t least 10
measurements made on prints enlarged 3 to
10 X from original negative plates.
Glycogen (PAS and
Bauer-Feulgen)
Without antecedent
diastase digestion
With diastase digestion
Iron
Lipid
Mucin
Amyloid
Reticulum
Trichrome
PTAH
Results
T h e results of the special stains and histochemical methods are tabulated in Tables 1
and 2 and can be summarized as follows. T h e
r h a b d o m y o m a cells contained much glycogen and a very small a m o u n t of lipid. Iron
and mucin were absent. Stains for amyloid
were negative. Reticulum fibers encircled
individual cells, and connective tissue was
scant. Cross-striations were well demonstrated with the P T A H stain. Acid phosphatase, alkaline phosphatase, and esterase
showed weak activity. A T P a s e activity was
marked in most cells. Succinic dehydrogenase activity was intense, especially a t the
periphery of t h e r h a b d o m y o m a cells. Within
t h e cytoplasm, succinic dehydrogenase-positive material occasionally exhibited a linear
distribution (Figs. 5 and 6).
Positive
Negative
Negative
Small amount present
Negative
Negative
Encircling cells
Scant connective
tissue
Occasional crossstriations
TABLE 2
ENZYME ACTIVITY (GRADED 0 TO 4 + ) IN
RHABDOMYOMA, GRANULAR CELL MYOBLASTOMA, AND NORMAL SKELETAL MUSCLE
Enzymes
Granular
RhabdoCell
myoma Myoblastoma
Acid phosphatase
Alkaline phosphatase
Esterase
ATPase
4+
1+
1 + Not done
3+
3+
Not done
Succinic dehydrogenase
3+
Not done
T
1+
* ype I and Type II fibers,
t Type II and Type I fibers.
Normal
Skeletal
Muscle
0
0
1+
1+ and
3+*
1+ and
3+t
.£ mf
F I G . 3 (upper left). Appearance of irregularly distributed crystal-like particles in rhabdomyoma
cell. Phosphotungstic acid hematoxylin. X 800.
F I G . 4 (upper right). Well defined cross-striations in rhabdomyoma cell. Phosphotungstic acid hematoxylin. X 800.
F I G . 5 (lower left). Marked ATPase activity in rhabdomyoma. X 190.
F I G G (lower right). Succinic dehydrogenase-positive material in rhabdomyoma concentrated a t
periphery of cells and demonstrating areas suggestive of linear arrangement. X 190.
785
7S6
CZERN0B1LSKY ET
the light microscope, almost all of the tumor
cells observed with the electron microscope
could be definitely identified as striated
muscle. In most there were large numbers of
myofibrils and myofibrillar fragments. Often
these consisted of tufts of myofilaments
attached to both sides of a single Z band or
joining together two or three Z bands in units
of irregular and varying size. Usually these
fragments were oriented at random in the
cytoplasm, and only occasionally were they
well organized with a series of Z bands in
more or less complete sarcomeres running in
parallel. Such well organized areas would
give the appearance of cross-striations by
light microscopy, whereas in areas of random
orientation, most of the isolated myofibrils
were below the limits of resolution of the
light microscope. A well organized area in
which the Z bands exhibited good alignment
is illustrated in Figure 7. The vacuoles seen
by light microscopy contained abundant
glycogen and occasional lipid droplets.
Occasional cells contained circumscribed,
roughly circular foci in which structures
interpreted as enlarged, irregular, and randomly oriented Z bands were present; these
often reached dimensions as large as 1 by 5 /n
(Fig. S). Numerous thin myofilaments were
inserted into these, although there was no
evidence of organization into sarcomeres.
Further details of the ultrastructure of this
tumor are reported elsewhere.4
DISCUSSION
The literature on rhabdomyoma was recently reviewed by Moran and Enterline, 16
who found a total of 11 cases and reported
one of their own. Since their report, an additional case of rhabdomyoma was published
by Tsukada and Pickren.27 The present report brings the number of cases in the literature to 14.
Nine of the tumors were in men and five
were in women. Age distribution ranged from
S weeks to SI years with no predilection for
any given age group. Eleven of the 14 tumors
were located in the head and neck region.
The others were found in the axilla, perineal
region, and chest wall. Duration of symptoms prior to removal of the lesion varied
considerably from 11 months to as long as 30
or 55 years.
AL.
Vol. 49
Ten of the patients were followed for
various lengths of time, up to 6 years postoperatively, without recurrence or metastasis. In the patient reported here the lesion
recurred 5 years after the initial operation,
which most likely was not a total resection.
He has been followed now for 12 months
after the second, more extensive resection
without evidence of recurrence.
The "crystals" within the rhabdomyoma
cells noted on light microscopy in both this
case and the case reported by Moran and
Enterline 16 were shown to correspond to the
highly hypertrophied Z band areas observed
in the electron microscope. The chemical
nature of this Z band material is still unknown, but it may be tropomyosin or a
closely related protein. These abnormal
structures appear similar to the hypertrophied Z bands seen in nemaline myopathy10 and to a lesser degree in denervation
atrophy of muscle.11 Mitochondria are seen
at the cell periphery and in linear rows between myofibrils in the portions of the cell
which show the highest degrees of organization. This arrangement correlates well with
the distribution of succinic dehydrogenase
seen in the histochemical portion of the
study.
The foci of hypertrophied Z bands in
rhabdomyoma have not been described in
the few cases of rhabdomyosarcoma subjected so far to ultrastructural studies. Although in some areas the organization of the
myofibrils approaches that of normal muscle,
in other areas the degree of fragmentation
and disorientation resembles more closely
that described in well differentiated rhabdomyosarcoma by Kroll and associates14 and by
Friedman and co-workers.8
As has been noted previously, the superficial resemblance of rhabdomyoma to granular cell myoblastoma is not indicative of any
relationship between these tumors. No crossstriations have ever been found in a granular
cell myoblastoma, and histochemical evidence also points to marked differences between these two lesions. Fisher and
Wechsler7 have emphasized the striking differences between granular cell myoblastoma
and normal striated muscle and have presented evidence for the neurogenic nature of
the granular cell myoblastoma.
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FIG. 7 (upper). Well organized area of the cytoplasm of a rhabdomyoma cell in which bundles of myofilaments (arrowheads) can be seen to join several Z disks (Z) in a succession of sarcomeric units which
simulate normal muscle but display abnormal branching and variation in size and arrangement. Arrows,
transverse tubules; M, mitochondria; G, glycogen. X 32,000.
FIG. S (lower). Cytoplasmic area corresponding to focus of "crystals" by light microscopy. These
are seen to consist of structures (Z) interpreted as enlarged and modified Z bands. They are often attached to bundles of thin myofilaments (arroivheads). G, glycogen. X 11,000.
787
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CZERNOBILSKY ET
The rhabdomyoma of striated muscle and
that of the heart bear more than a superficial resemblance. In both lesions crossstriations are present; both contain glycogen
and both demonstrate vacuolization of cells.
However, as has been pointed out by Moran
and Enterline, 16 the cardiac rhabdomyoma
cells are larger, with a more uniform vacuolization than those of the rhabdomyoma of
striated muscle. Cross-striations of the cardiac rhabdomyoma are numerous and
appear compressed by the vacuoles, whereas
in the extracardiac lesion the cross-striations
are rare and difficult to find. The haphazardly arranged crystals constituting hypertrophiedZ bands which can be observed in
the extracardiac rhabdomyoma have not
been described in the cardiac lesion. Although more than half of the cardiac rhabdomyomas reported have been associated with
tuberous sclerosis, such an association has
not been reported to date in any of the extracardiac rhabdomyomas.
There also may be enzymatic differences
between the cardiac and extracardiac rhabdomyoma, as Golding and Reed 9 reported
that a cardiac rhabdomyoma demonstrated
neither succinic dehydrogenase nor ATPase
activity, although their failure to demonstrate ATPase may be due to the method
used. Succinic dehydrogenase and ATPase
activity were marked in the extracardiac
rhabdomyoma reported here. Unfortunately,
no ultrastructural study of cardiac rhabdomyoma has been published for comparison.
SUMMARY
This is a report of a rhabdomyoma of the
retropharynx in a 39-year-old man. For the
first time histochemical enzyme reactions
and ultrastructural studies have been performed on this lesion. These studies served
to confirm its origin from striated muscle.
Ultrastructural studies have established that
the "crystals" seen in extracardiac rhabdomyoma by light microscopy represent abnormal hypertrophied Z bands similar in size
and type to those seen in nemaline myopathy. The tumor differs sharply in enzyme
pattern and structure from both granular
cell myoblastoma and cardiac rhabdomyoma.
Ah.
Vol. 49
Acknowledgments. Technical assistance was
rendered by Mr. Joseph Martin and Bonnie Faye
Karch, H.T. (ASCP).
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