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Myoblastic myoma
Oral
Pathology
MYOBLASTIC 1)OKALD
A.
&RR,
l).I).s.,
MYOMA
BI.s.,’
ANN ARBOR,?VtICH.
TUMOR entity described in 1.926 by Abrikossoffl under the name myoblastic myoma has since been described as myoblastoma, granular-cell Alt.hough similar myoblastoma, rhabdomyoma, and fibrocytoma granulare. single lesions had previously been reported as rhabdomyoma” and xant,homa,3 it, was Abrikossoff’s report of five cases which established this lesion as an entity associated with striated muscle. Since 1926 the tumor has frcquent.ly been described in the literature. Crane and Tremblay” in a thorough review of the Merature in 1945 collected 157 cases and added five of their own. Since 1926 Simon5 has reported 6 cases, PowellG 3, Bernier? 17, and numerous single cases have appeared in the literat.ure. Malignant granular-cell myoblastomas have been reported by AckermanF” The number of cases reported Ravich, Stout, and Ravich,s and Khano1kar.l” since 1926 indicates that the tumor is of infrequent. occurrence, and the numerous synonyms suggest that t,he histogcnesis is not well underst.ood.
A
Clinical Characteristics The tumors appear at any age, but arc most frequent in the third, fourth, and fifth decades. They are frequently congenital in the alveolar process, and one case was reported in the breast of a woman 79.‘l They appear in both The lesions appear in all parts of the body with sexes with equal frequency. the highest incidence in the tongue? alveolar process, subcutis, and skin. The lesions are usually small (0.5-2 cm.), sharply circumscribed, discrete, elevat.4 tumors, having a gray to grayish white, smooth surface. In a few instances The tumors are firm, nontender, and the lesions are polypoid or ulcerated. rllyomay show gradual increase in size. Although malignant gram&r-cell bla.stomas have been reported, the t.umors are usually bcnigu, and a cure is when effected with complete local escaision. Recurrences hilye bean report4 removal was incomplete.
Morphologic Features Gross Characteristics.-The tumors are 0.5-2 cm. in size, although
myo-
They arc usually sharply cirblast.omata up to 10 cm. have been reported.‘” cumscribed, occasionally encapsulated, stn0ot.h masses. Lobulated and poorly 1948.
Head before the meeting of the American
*Assistant Professor tvniversity of Michigan.
of Drntistry
kademy
:mcl Assistant
of Oral Pathology, Professor
of Ikthologg,
Chicago,
February.
Medical
Scho01.
defined infiltrating forms occur. They are usually subepithelial with the overlying epithelium smooth a,ncl regular. ln some cases the epithelium is hyperplastic, and carcinomatous change is seen.‘:’ ()n cut section the tumor is firm and gray to grayish yellow in color.
Microscopic Characteristics.-The most outstanding feature is the large, rounded, pale, granular cells. The cells are round to polyhedral in shape with sotilt! elongated and spindle forms. They are W-60 TT. in diameter with thv elongated cells bring as much as 300 li. in length. The cells are in syncytial masses.ancl ribbonlike IWWS with delicate connective tissue fibrils and strands separating the individual cells or groups. Occasional remnants 0 muscle fibers are a.lso interspersed. The cytoplasm is abundanb, granular, alld varies from slight.ly basophilic to intensely eosinophilic due to the variation in sizta and number of’ the granules. Tn some ~ast’s the gixnules are arranged in irregular rows producing a fibrillar effect. Goss and longit.uditial striations hav(! been demonstrated, lmt not. cacmsistent,ly. The nuclei are rouncl to oval. vesicular, ant1 caent.rally placed. Pyknotic a.ntl spindle forms somet.imes oc(*nr. IM+rentiaI diagnosis is with sa~~thomas ancl rhal)tlomyosarconlas. Case Reports Case l.-The patient, a 4’7-year-old man, noticed a small lump on his tongue for the past four months. On cxaminatoin there was a slightly elevated grayish area 2 by 2 cm. on t.he dorsum of the t.ongue. The area was well circumscribed, firm, and asymptomatic. The remainder ot’ the physical examination was negative. The gross specimen was a pea-sized grayish nodule beneath an intact epithelial surface. Microscopically the epithelium over the surface was hyperplastic with some increase in kerat.ohyalin oti the surface. Beneath the epithelium there were large polyhedral cells containing a pale granular cytoThe submuc.oua connective plasm and a cent.rally placed veaicu1a.r nucleus. t.issue and muscle were replaced by the large granular cells. Small residual muscle fibers were interspersed bet.wcen the groups of cells.
Case 2.-The patient was a G-week-old infant with a pea-sized mass on the lower alveolar ridge near the cuspid region. The mass had been present since Physical examination was negnbirth without change in size or character. tive. Prepared slide was submit.ted by Dr. .J. B. 8. Microscopically this wa.s a small polypoid mass covered by a slightly thickened mucous membrnnc. Beneath the epithelium invading the sulm~uc.osa were numerous large oval t.n polyhedral cells. The cytoplasm was finely gra.nular and had a slight basophilic quality. The nuclei were small and ovaI to spindle in shape. The chromatin was granular but compact. The cc?llw invnded the connective tissue! and there was no evidenca of a capsule. lIiugno.sis:
Myoblast.ic myoma or so-called “epulis
of t.116newborn.”
MY OBLAATIC
YYOM
A
13
Case 3.-The patient, a white married woman, for one year had been aware of a firm, slightly elevated, grayish asymptomatic lesion 1 cm. in diameter on the right lateral and dorsa.1 surfaces of the tongue. Physical examination was negative. Microscopic examination revealed a normal mucosal surface beneath which was a well-circumscribed area composed of very large rounded cells conbaining abundant granular cytoplasm. Variation in the size of the cells was noticeable, with the larger cells having a marked dispersion of the granules. The nuclei were vesicular and centrally placed. The cells were arranged in masses and ribbons duplicating somew-hat the pattern of tongue muscle. The individual cells were separated by delicate connective tissue fibrils while larger groups of cells were separated by heavier connective tissue sept.a. Diagnosis:
Myoblastic
myoma.
Case 4.-The patient, a white married woman aged 26, complained of a tumor of her tongue. In October, 1945, she noticed a swelling of the right side of her tongue. She had the impression t.hat the tongue was twice normal size. The swelling disappeared in about two hours. Two weeks following the swelling the patient was aware of a thickening and tumescence on the right lateral margin of the tongue. There were two or t.hree episodes of swclling previous to December, 1945, after which there was no swelling, but the tumor persisted. The patient was pregna.nt at the time of examination and 111 May, 1946, she I’+ was advised to delay treatment until after delivery. turned for treatment. The tumor had decrea,secl in size and now measurrtl Il.5 by 1 cm. It was situated on the right lateral margin approximately at the It was firm and of a lighter junction of the anterior and middle one-third. color than the surrounding mucosa. The gross specimen measured 3 by 2 by 2.5 cm., and there was a firm grayish nodule 2 by 1.5 cm. beneath the mucosa. Microscopically the tumor was conq~oscd of large rounded cells wit.h an abundant finely granular cytoplasm which wa.s only slightly eosinophilic. The nuclei were round, vesicular, a,nd in the center of the cell. Single cells and small groups of cells invaded and replaced the tongue muscle. Residual muscle fibers and delicate connective t.issue strands separated the tumor cells into varying sized masses. Diagnosis:
Myoblastic
myoma.
Case B.-Two prepared slides, from a biopsy of t.he lip, were prescntcd I)!: Dr. C1.E. B, No other history was available. Microscopically there was a small, discrete mass composed of moderatesized polygona. to spindle cells having a granular cytoplasm. Nuclei were vesicular and round, spindle and pyknotic in character. Diagnosis:
Myoblastic
myoma.
Case &-The pa.tient, presented with history was available.
;I growt.11 on tbr tongue.
No other
44
DOKALD A. KERR
Microscopically t.he surface epithelinm was slight.ly hypcrplastic with deep rete pegs. There were isolated areas of egithelium benctlth the sm*Iacct. The subepithelial tissue was composed of large round to polyhedra.1 The granules had a cells h;l\Gllg it finely granular cosinol)hilic cytopla,snl. The: cells cluplicated the pattern of fll~~~illill’ ;irmngeinent ill. many arcas. tongue muxclc with fas~!i(!ulus being selxl.ratxcl I)y 4elicat.c conneotivcs disaue thiu,
fil,rils.
Rcsic’lunl nlnscle cells were I)rc~selll;.
Dir~gnosis: thigh
nlyohlast~ie
myoma.
Case 7.-The ])atient;. a white of ;I. f’thw IIIOII~?~’ duration.
ntan 24 years of age, had a l~n~p 011 the right 31, other history was available.
of large, rounded, polyhedral Mic’~osc’~,l)iaaIIy the tumor \vil.s co~I~posstl cells h;l.ring illI ~Il~un~l~~~lt, fillcly granular, l)a.le eosinophilic cytoplasm. The nucleoli. nucl.ri were \-~ry l.arg:~. nlarketlly \:;f!sicular, ilntl chontained prominent ‘l:)ense Init. d(~li(!iltl~ connective tissucl filers il.lld occasional muscle fibers were present.
Difq
osis: Myoblastic
myoma.
Case S.--The patient, a SO-year-old SUYf'iK!(' of the I-ongue I. Cm. in diameter. lllont.hs. Ko other history WIS available. There
wt’r(’ three
prq)aretl
slides front
man, Ililt a growth OII the tmterior This had been present for about. six the V. W. Hospital.
.~¶ic?rosct)l)ici;llly the ~.UIHOI: \vils ~natlt! UJ> of’ la.~ge rounded cells having a The nuclei fine griLtllllilr cytoplasm which was only slightly eosinophilic. of the cell. Fine fibrillar strands wet*e l*0Ulltl. VWi(?Lllil I’, a1111 in the center Portions of ~l~uscle fibers were associated with the separated groups of cells. tllmor cells. Diftgn 0si.s:
Mjddast
ic: myoma.
Case 9.-The patient,, it M-year-old I)tillt, hatI iltl ulcer OII the tongue which was Ijrescnt. Tar approximately six months. The ulcer was modera.tely painful l+:xainination revealed a small ulcer 0.5 when food was t.aken into the m0ut.h. cm. in diamet,er on the tip oB the tongue slightly to the left. of the midline. The borders were slightl,v raised and indura.tetl, and the base! was fluffy gray,. The
rcmaintlcr
of the! pli.uiical
examination
was negativr.
~~ic!.rosco~~icall~ the 1(&n was papillotnatous with a marked hyperplasia. of thr I~~ws;~. There \va.s epithelial proliferation wibh invasion and 1a.c.k 0.1 differentiation. Sumcrons nests of atppica.1 epithelial cells having cornificd centers were deep in the tissue. Thr tissue being invaded was composed of large roundctl ~11s having a. pale eosinophilic?. gra.nular c\-toplasm. The nuclei were 1~01llld.
\‘CS~f~li~ill~.
Diagnosis:
iilld
lY?lltY;l~~;\,
( 2)rnifying
T)lClCCt!. S~~1liIITlOlIS-~~Cll
ca.rcinomtl
infiltrating
;I myoblastic
myoma. othrr
Case 10.-The patient, was a SO-year-old history was avai1a.M~~.
woman.
“Tumor
from
back. ”
R;o
MYOBIASTIC
MYOMA
45
Grossly this was a firttt. loln~ln.ted. homogeneous, dark, yellowish l~own mass. Microscopically the tissue had a lobulated appearance with the lolntles made nI) of large rounded cells having a,n eosinophilic granular cytoplnstn. In sotno cells granules were coarse while in others they were fine. The vesicula t’ nuclei were cendrally placed. These cells invaded n.tlipost~ l;issue and stt*iat.eil muscle. Sicharlach R stain on frozen sections showed the laryc gr:ttlUlitr cells to contain st.aittaltlr lipid.
lhynosis:
Liponta arisitt p front brown fat (vestigial
ltil~ernatittg
gland).
Discussion The histogenesis of t,his tumor presents many problems, attd ttutnerotts opinions have been offered as to its t.ruc nature. Abrikossoff’ in his first rel)ot*t suggest.ed the t.untor arose front tnyoblasts in areas where tnuscle wits tlrgenetxting front trauma or inflattttttation. Gray and Gruet~feld,‘2 Ewing.” ant1 Eernier’ subscribe to t,his view. In his second reported series Abrikossoff’” ittderpreted t,he tumors as arising frotn premature tnyoblasts as hacl been suggestctl by Klingc.‘” Cirtty and Gruettf eldx2 suggcst.ed that ~.hc tumor cells developed from ntat.ure myob1ast.s but. did not develop into mature tnusclc aells. and indicabrd they were tnyoblasts undergoing necrobiosis. Wolbach” ittttl UodlewskilR pointed out that the granules were t.he same as those sent itt dcveloping myofibrils, and demonstrated that t.hese granules were aligned to produce both cross and longitudinal striations (Fig. 1). Klingel’” and others believe t.he tumor is ilysotttogenetic in origin wit.h tltosc tlcvelopitig in arcas where tttuscle is not nortna.lIy present being clnc to cttihryologic association in the pritttitive segment. Tltc cases subtttittcd csltibit cttarac+cristirs which support lltc various 1heories of hist.ogenesis. In tlte tottguc, some of t.ltc titusele cells have acquiretl a. swollett ~t~tltlltliIl~ Thth atteretl cells ;ttt(l ttot*tnitl CCIIS, cl.]~~)e;ttXtlce suggest.ive d tlepetl~t~iltiOll. This is albhough interntingled, retain the Ixt.t,tertt OF stt*i;tt,ctl muscle. st.rottgly in favor of the degetterntiott followittg trauma hypothesis of hist,ochanges in the surt*outttling genesis (Fig. 2). The absrnce of reparative strontn and overlying epithcliunt tloes ttot strettg;thett the ttxutttntia throt*y of origin. Because lesions ot.her thittt those of the t,ottgus tlo not ch;tt*;t(*tet*istically show the Sante relationship of ~t~illlllIil~ and ?tOlmil.I CCltS in tllc Ixtt.tertt of striated tnuscle, it is possible t,h;t.t a sittgle term is beittg used to describe two different hut sintilar lesions. The occurrence of t.his tumor in itt*eit.s where striateti tnttscle is ttot ttot*tnalty present and its eongettititl a.I)I)earttnee ott the alveolttr ridge supI>ot*t the clysontogenetic theory of origin (Fig. 3). The variation in cellular detail a.ntl the inability of the lesions other thatl those of t,he tongue to duplicate the ppnttertt of st.riated tnuscle (Fig. 4) favor The t.ettdency for t*eeUt*rettce I’ollowittg the neaplastic theory of histogettesis. incomplete removal gives added support to the neoplastic concept. Although
DON.ALD A. KERR
Fig. 1.
Fig.
2.
Fig. l.-Case 3. Large v>lcuolatetl and gr;mular cosinophilic cells replacing mus de fiber Longitudinal arrangement nt fibrilz: simulating developing muscle. Supports theory of cleve?~pmental origin of this tumor. Fig. P.-Case 3. Lu.rge eosinophilic granular cells erranged in pattern of muscle bundl’ es. Hesi dual muscle fibers interspersed between the tumor cells. Preservation of muscular patte !T?l and swollen granular vucuolated cells support theory of degeneration.
MYOBLAslw
MYOMA
Fig.
3.
Fig.
4.
47
Fig. 3.--Case 3. Large finely granular eosinophilic cells without a deflnite growth Pattern. The complete replacement of muscle pattern and growth pattern of the tumor Cells supports the neoplastic theory of histogenesis. Fig. 4.-Case 3. The cells although smaller have the same morphologic characteristics. There is marked The tongue architecture has been entirely replaced by neoplastic cells. proliferation of the surface epithelium with infiltrative growth. This also supports the neoplastic theory of histogenesia.
48
t)ONALD
A. KERK
nialignant forms are difficult to diiTerenti;lte frown ~~h~~l~do~~~y~~s~~r~!~~~~~a., the frequent yecent, reports of t.his lesioil produGtig nM,astasis n~usf- be given consideration and arc, therefore, supporting rvi(lcnc*c of the! Ileopl;~st.i(* (!hara(*ter of this lesion. Although the preponderance OE evitlence al)l)ears to favor the tnyoblastic The nlyonla being a neoplasln, t.he question of its histogrnesis is unanswered. most. satisfactory conclusion at present. is that of (!rane mtl ‘I’remhlay which states, ‘
Fig. .X-Case 10. Large eosinophilic granular cells intermingled with vacuolated cells. Invasion between muscle flbers and adipose tissue cells. Muscle flbers are intact and not invaded as in other cases. Vacuolated cells are positive for fat with Sudan III stain.
References 1. Abrikossoff, -4.: Ueber Myome, Ausgehend van tier quergestreiften willkiirlichen Muskulatur, Virchowx Srch. f. path. Anat. 260: 215-233, 1926. 2. Penal, F.: TJeber ein congenitales Rhabdomyom der Zunge, Ztschr. f. IIeilk. 18: 457468, 1897.
MYORLASTIC
MYOMA
49
3. Moschcowitz, El.: Xanthoma of the Tongue, Proc. New York Path. Sot. 22: 135-141, 1922. 4. Crane. A. R.. and Tremblav. R. G.: >fvoblastoma. Am. J. Path. 21: 355-3i2. 1945. 5. Simon, &I. A.: Granular Eel1 Myobla&oma,. Am.‘J. Clin. Path. 17: 302-31$ 1947. ti. Powell, E.: Granular Cell Mvoblastoma, Arch. Path. 42: 517-524, 1946. i. Hernier, .J. L.: Myoblast&a, Am. J. brthodontirs and Oral 8urg. (Oral Burg. Sect.) 33: 548-551, 194i. X. Ackerman, JA. V.: 3Ialignant Granular Cell Myoblastoma of the Gluteal R,egion, Surgery 20: 511-519, 1946. 9. Ravich, A., Stout, A. P., and Ravieh, R. A.: Malignant Granular (‘ell Myoblastorna of Urinary Bladder, Am. J. Surg. 121: 361-372, 1945. 11). Khanolkar, V. R.: Grauular (lell Myoblastoma, Am. .T. Path. 23: 721-739, 1947. 11. stout, A. P.: Granular Cell Myoblastoma of the Breast, -1. Missouri 11. A. 44: 342344? 194T. 1% Gre\-, S. H., and Gruenfeld, G. E.: Myoblastoma, Am. .T. Cancer 30: 699-708, 1937. 13. Klemperer, Paul: Myoblastoma of Mriated Muscle, Am. J. Cancer 20: 324-337, 1934. 1-I. Ewing, .l. 1%: Neoplastic Ijiseases, ed. 4, Philadelphia, 1942, \V. H. Saunders Company.
15. Xbrikossoff, A.: \Veitere TJntersuchungen ueber l\lyoblastenm~olt~e, ‘Yirchows Arch. f. path. Anat. 280: 723-740, 19X.1. Ifi. Ming:, F.: I:eber die sogenannten unreifen, nicht quergestreiften Nyoblastermyome, C erhandl. d. deutsch. path. Qesellsch. 23: 376-332, 1928. 17. Wolbach, R. B.: Centrioles and the Histogenesis of the ?iIyofibril in Tumors of Rtriated Muscle Origin, Anat. Rec. 37: 255-262, 1928. 1-L Godlewski, ‘E:.: 1)ie Entwicklung des Skelet- und Herz-mus pelgewebes der Saugethiere, Arch. f. mikr. Anat. 60: 111-156, 1902. 19. Priutr, 1). H., Cole, H’. x., and l)river: J. R.: I*Iyoblastorna, Brch. Dormat. & Syph. 55: 2!)i-L)RR, 1919.
Pathology
MYOBLASTIC 1)OKALD
A.
&RR,
l).I).s.,
MYOMA
BI.s.,’
ANN ARBOR,?VtICH.
TUMOR entity described in 1.926 by Abrikossoffl under the name myoblastic myoma has since been described as myoblastoma, granular-cell Alt.hough similar myoblastoma, rhabdomyoma, and fibrocytoma granulare. single lesions had previously been reported as rhabdomyoma” and xant,homa,3 it, was Abrikossoff’s report of five cases which established this lesion as an entity associated with striated muscle. Since 1926 the tumor has frcquent.ly been described in the literature. Crane and Tremblay” in a thorough review of the Merature in 1945 collected 157 cases and added five of their own. Since 1926 Simon5 has reported 6 cases, PowellG 3, Bernier? 17, and numerous single cases have appeared in the literat.ure. Malignant granular-cell myoblastomas have been reported by AckermanF” The number of cases reported Ravich, Stout, and Ravich,s and Khano1kar.l” since 1926 indicates that the tumor is of infrequent. occurrence, and the numerous synonyms suggest that t,he histogcnesis is not well underst.ood.
A
Clinical Characteristics The tumors appear at any age, but arc most frequent in the third, fourth, and fifth decades. They are frequently congenital in the alveolar process, and one case was reported in the breast of a woman 79.‘l They appear in both The lesions appear in all parts of the body with sexes with equal frequency. the highest incidence in the tongue? alveolar process, subcutis, and skin. The lesions are usually small (0.5-2 cm.), sharply circumscribed, discrete, elevat.4 tumors, having a gray to grayish white, smooth surface. In a few instances The tumors are firm, nontender, and the lesions are polypoid or ulcerated. rllyomay show gradual increase in size. Although malignant gram&r-cell bla.stomas have been reported, the t.umors are usually bcnigu, and a cure is when effected with complete local escaision. Recurrences hilye bean report4 removal was incomplete.
Morphologic Features Gross Characteristics.-The tumors are 0.5-2 cm. in size, although
myo-
They arc usually sharply cirblast.omata up to 10 cm. have been reported.‘” cumscribed, occasionally encapsulated, stn0ot.h masses. Lobulated and poorly 1948.
Head before the meeting of the American
*Assistant Professor tvniversity of Michigan.
of Drntistry
kademy
:mcl Assistant
of Oral Pathology, Professor
of Ikthologg,
Chicago,
February.
Medical
Scho01.
defined infiltrating forms occur. They are usually subepithelial with the overlying epithelium smooth a,ncl regular. ln some cases the epithelium is hyperplastic, and carcinomatous change is seen.‘:’ ()n cut section the tumor is firm and gray to grayish yellow in color.
Microscopic Characteristics.-The most outstanding feature is the large, rounded, pale, granular cells. The cells are round to polyhedral in shape with sotilt! elongated and spindle forms. They are W-60 TT. in diameter with thv elongated cells bring as much as 300 li. in length. The cells are in syncytial masses.ancl ribbonlike IWWS with delicate connective tissue fibrils and strands separating the individual cells or groups. Occasional remnants 0 muscle fibers are a.lso interspersed. The cytoplasm is abundanb, granular, alld varies from slight.ly basophilic to intensely eosinophilic due to the variation in sizta and number of’ the granules. Tn some ~ast’s the gixnules are arranged in irregular rows producing a fibrillar effect. Goss and longit.uditial striations hav(! been demonstrated, lmt not. cacmsistent,ly. The nuclei are rouncl to oval. vesicular, ant1 caent.rally placed. Pyknotic a.ntl spindle forms somet.imes oc(*nr. IM+rentiaI diagnosis is with sa~~thomas ancl rhal)tlomyosarconlas. Case Reports Case l.-The patient, a 4’7-year-old man, noticed a small lump on his tongue for the past four months. On cxaminatoin there was a slightly elevated grayish area 2 by 2 cm. on t.he dorsum of the t.ongue. The area was well circumscribed, firm, and asymptomatic. The remainder ot’ the physical examination was negative. The gross specimen was a pea-sized grayish nodule beneath an intact epithelial surface. Microscopically the epithelium over the surface was hyperplastic with some increase in kerat.ohyalin oti the surface. Beneath the epithelium there were large polyhedral cells containing a pale granular cytoThe submuc.oua connective plasm and a cent.rally placed veaicu1a.r nucleus. t.issue and muscle were replaced by the large granular cells. Small residual muscle fibers were interspersed bet.wcen the groups of cells.
Case 2.-The patient was a G-week-old infant with a pea-sized mass on the lower alveolar ridge near the cuspid region. The mass had been present since Physical examination was negnbirth without change in size or character. tive. Prepared slide was submit.ted by Dr. .J. B. 8. Microscopically this wa.s a small polypoid mass covered by a slightly thickened mucous membrnnc. Beneath the epithelium invading the sulm~uc.osa were numerous large oval t.n polyhedral cells. The cytoplasm was finely gra.nular and had a slight basophilic quality. The nuclei were small and ovaI to spindle in shape. The chromatin was granular but compact. The cc?llw invnded the connective tissue! and there was no evidenca of a capsule. lIiugno.sis:
Myoblast.ic myoma or so-called “epulis
of t.116newborn.”
MY OBLAATIC
YYOM
A
13
Case 3.-The patient, a white married woman, for one year had been aware of a firm, slightly elevated, grayish asymptomatic lesion 1 cm. in diameter on the right lateral and dorsa.1 surfaces of the tongue. Physical examination was negative. Microscopic examination revealed a normal mucosal surface beneath which was a well-circumscribed area composed of very large rounded cells conbaining abundant granular cytoplasm. Variation in the size of the cells was noticeable, with the larger cells having a marked dispersion of the granules. The nuclei were vesicular and centrally placed. The cells were arranged in masses and ribbons duplicating somew-hat the pattern of tongue muscle. The individual cells were separated by delicate connective tissue fibrils while larger groups of cells were separated by heavier connective tissue sept.a. Diagnosis:
Myoblastic
myoma.
Case 4.-The patient, a white married woman aged 26, complained of a tumor of her tongue. In October, 1945, she noticed a swelling of the right side of her tongue. She had the impression t.hat the tongue was twice normal size. The swelling disappeared in about two hours. Two weeks following the swelling the patient was aware of a thickening and tumescence on the right lateral margin of the tongue. There were two or t.hree episodes of swclling previous to December, 1945, after which there was no swelling, but the tumor persisted. The patient was pregna.nt at the time of examination and 111 May, 1946, she I’+ was advised to delay treatment until after delivery. turned for treatment. The tumor had decrea,secl in size and now measurrtl Il.5 by 1 cm. It was situated on the right lateral margin approximately at the It was firm and of a lighter junction of the anterior and middle one-third. color than the surrounding mucosa. The gross specimen measured 3 by 2 by 2.5 cm., and there was a firm grayish nodule 2 by 1.5 cm. beneath the mucosa. Microscopically the tumor was conq~oscd of large rounded cells wit.h an abundant finely granular cytoplasm which wa.s only slightly eosinophilic. The nuclei were round, vesicular, a,nd in the center of the cell. Single cells and small groups of cells invaded and replaced the tongue muscle. Residual muscle fibers and delicate connective t.issue strands separated the tumor cells into varying sized masses. Diagnosis:
Myoblastic
myoma.
Case B.-Two prepared slides, from a biopsy of t.he lip, were prescntcd I)!: Dr. C1.E. B, No other history was available. Microscopically there was a small, discrete mass composed of moderatesized polygona. to spindle cells having a granular cytoplasm. Nuclei were vesicular and round, spindle and pyknotic in character. Diagnosis:
Myoblastic
myoma.
Case &-The pa.tient, presented with history was available.
;I growt.11 on tbr tongue.
No other
44
DOKALD A. KERR
Microscopically t.he surface epithelinm was slight.ly hypcrplastic with deep rete pegs. There were isolated areas of egithelium benctlth the sm*Iacct. The subepithelial tissue was composed of large round to polyhedra.1 The granules had a cells h;l\Gllg it finely granular cosinol)hilic cytopla,snl. The: cells cluplicated the pattern of fll~~~illill’ ;irmngeinent ill. many arcas. tongue muxclc with fas~!i(!ulus being selxl.ratxcl I)y 4elicat.c conneotivcs disaue thiu,
fil,rils.
Rcsic’lunl nlnscle cells were I)rc~selll;.
Dir~gnosis: thigh
nlyohlast~ie
myoma.
Case 7.-The ])atient;. a white of ;I. f’thw IIIOII~?~’ duration.
ntan 24 years of age, had a l~n~p 011 the right 31, other history was available.
of large, rounded, polyhedral Mic’~osc’~,l)iaaIIy the tumor \vil.s co~I~posstl cells h;l.ring illI ~Il~un~l~~~lt, fillcly granular, l)a.le eosinophilic cytoplasm. The nucleoli. nucl.ri were \-~ry l.arg:~. nlarketlly \:;f!sicular, ilntl chontained prominent ‘l:)ense Init. d(~li(!iltl~ connective tissucl filers il.lld occasional muscle fibers were present.
Difq
osis: Myoblastic
myoma.
Case S.--The patient, a SO-year-old SUYf'iK!(' of the I-ongue I. Cm. in diameter. lllont.hs. Ko other history WIS available. There
wt’r(’ three
prq)aretl
slides front
man, Ililt a growth OII the tmterior This had been present for about. six the V. W. Hospital.
.~¶ic?rosct)l)ici;llly the ~.UIHOI: \vils ~natlt! UJ> of’ la.~ge rounded cells having a The nuclei fine griLtllllilr cytoplasm which was only slightly eosinophilic. of the cell. Fine fibrillar strands wet*e l*0Ulltl. VWi(?Lllil I’, a1111 in the center Portions of ~l~uscle fibers were associated with the separated groups of cells. tllmor cells. Diftgn 0si.s:
Mjddast
ic: myoma.
Case 9.-The patient,, it M-year-old I)tillt, hatI iltl ulcer OII the tongue which was Ijrescnt. Tar approximately six months. The ulcer was modera.tely painful l+:xainination revealed a small ulcer 0.5 when food was t.aken into the m0ut.h. cm. in diamet,er on the tip oB the tongue slightly to the left. of the midline. The borders were slightl,v raised and indura.tetl, and the base! was fluffy gray,. The
rcmaintlcr
of the! pli.uiical
examination
was negativr.
~~ic!.rosco~~icall~ the 1(&n was papillotnatous with a marked hyperplasia. of thr I~~ws;~. There \va.s epithelial proliferation wibh invasion and 1a.c.k 0.1 differentiation. Sumcrons nests of atppica.1 epithelial cells having cornificd centers were deep in the tissue. Thr tissue being invaded was composed of large roundctl ~11s having a. pale eosinophilic?. gra.nular c\-toplasm. The nuclei were 1~01llld.
\‘CS~f~li~ill~.
Diagnosis:
iilld
lY?lltY;l~~;\,
( 2)rnifying
T)lClCCt!. S~~1liIITlOlIS-~~Cll
ca.rcinomtl
infiltrating
;I myoblastic
myoma. othrr
Case 10.-The patient, was a SO-year-old history was avai1a.M~~.
woman.
“Tumor
from
back. ”
R;o
MYOBIASTIC
MYOMA
45
Grossly this was a firttt. loln~ln.ted. homogeneous, dark, yellowish l~own mass. Microscopically the tissue had a lobulated appearance with the lolntles made nI) of large rounded cells having a,n eosinophilic granular cytoplnstn. In sotno cells granules were coarse while in others they were fine. The vesicula t’ nuclei were cendrally placed. These cells invaded n.tlipost~ l;issue and stt*iat.eil muscle. Sicharlach R stain on frozen sections showed the laryc gr:ttlUlitr cells to contain st.aittaltlr lipid.
lhynosis:
Liponta arisitt p front brown fat (vestigial
ltil~ernatittg
gland).
Discussion The histogenesis of t,his tumor presents many problems, attd ttutnerotts opinions have been offered as to its t.ruc nature. Abrikossoff’ in his first rel)ot*t suggest.ed the t.untor arose front tnyoblasts in areas where tnuscle wits tlrgenetxting front trauma or inflattttttation. Gray and Gruet~feld,‘2 Ewing.” ant1 Eernier’ subscribe to t,his view. In his second reported series Abrikossoff’” ittderpreted t,he tumors as arising frotn premature tnyoblasts as hacl been suggestctl by Klingc.‘” Cirtty and Gruettf eldx2 suggcst.ed that ~.hc tumor cells developed from ntat.ure myob1ast.s but. did not develop into mature tnusclc aells. and indicabrd they were tnyoblasts undergoing necrobiosis. Wolbach” ittttl UodlewskilR pointed out that the granules were t.he same as those sent itt dcveloping myofibrils, and demonstrated that t.hese granules were aligned to produce both cross and longitudinal striations (Fig. 1). Klingel’” and others believe t.he tumor is ilysotttogenetic in origin wit.h tltosc tlcvelopitig in arcas where tttuscle is not nortna.lIy present being clnc to cttihryologic association in the pritttitive segment. Tltc cases subtttittcd csltibit cttarac+cristirs which support lltc various 1heories of hist.ogenesis. In tlte tottguc, some of t.ltc titusele cells have acquiretl a. swollett ~t~tltlltliIl~ Thth atteretl cells ;ttt(l ttot*tnitl CCIIS, cl.]~~)e;ttXtlce suggest.ive d tlepetl~t~iltiOll. This is albhough interntingled, retain the Ixt.t,tertt OF stt*i;tt,ctl muscle. st.rottgly in favor of the degetterntiott followittg trauma hypothesis of hist,ochanges in the surt*outttling genesis (Fig. 2). The absrnce of reparative strontn and overlying epithcliunt tloes ttot strettg;thett the ttxutttntia throt*y of origin. Because lesions ot.her thittt those of the t,ottgus tlo not ch;tt*;t(*tet*istically show the Sante relationship of ~t~illlllIil~ and ?tOlmil.I CCltS in tllc Ixtt.tertt of striated tnuscle, it is possible t,h;t.t a sittgle term is beittg used to describe two different hut sintilar lesions. The occurrence of t.his tumor in itt*eit.s where striateti tnttscle is ttot ttot*tnalty present and its eongettititl a.I)I)earttnee ott the alveolttr ridge supI>ot*t the clysontogenetic theory of origin (Fig. 3). The variation in cellular detail a.ntl the inability of the lesions other thatl those of t,he tongue to duplicate the ppnttertt of st.riated tnuscle (Fig. 4) favor The t.ettdency for t*eeUt*rettce I’ollowittg the neaplastic theory of histogettesis. incomplete removal gives added support to the neoplastic concept. Although
DON.ALD A. KERR
Fig. 1.
Fig.
2.
Fig. l.-Case 3. Large v>lcuolatetl and gr;mular cosinophilic cells replacing mus de fiber Longitudinal arrangement nt fibrilz: simulating developing muscle. Supports theory of cleve?~pmental origin of this tumor. Fig. P.-Case 3. Lu.rge eosinophilic granular cells erranged in pattern of muscle bundl’ es. Hesi dual muscle fibers interspersed between the tumor cells. Preservation of muscular patte !T?l and swollen granular vucuolated cells support theory of degeneration.
MYOBLAslw
MYOMA
Fig.
3.
Fig.
4.
47
Fig. 3.--Case 3. Large finely granular eosinophilic cells without a deflnite growth Pattern. The complete replacement of muscle pattern and growth pattern of the tumor Cells supports the neoplastic theory of histogenesis. Fig. 4.-Case 3. The cells although smaller have the same morphologic characteristics. There is marked The tongue architecture has been entirely replaced by neoplastic cells. proliferation of the surface epithelium with infiltrative growth. This also supports the neoplastic theory of histogenesia.
48
t)ONALD
A. KERK
nialignant forms are difficult to diiTerenti;lte frown ~~h~~l~do~~~y~~s~~r~!~~~~~a., the frequent yecent, reports of t.his lesioil produGtig nM,astasis n~usf- be given consideration and arc, therefore, supporting rvi(lcnc*c of the! Ileopl;~st.i(* (!hara(*ter of this lesion. Although the preponderance OE evitlence al)l)ears to favor the tnyoblastic The nlyonla being a neoplasln, t.he question of its histogrnesis is unanswered. most. satisfactory conclusion at present. is that of (!rane mtl ‘I’remhlay which states, ‘
Fig. .X-Case 10. Large eosinophilic granular cells intermingled with vacuolated cells. Invasion between muscle flbers and adipose tissue cells. Muscle flbers are intact and not invaded as in other cases. Vacuolated cells are positive for fat with Sudan III stain.
References 1. Abrikossoff, -4.: Ueber Myome, Ausgehend van tier quergestreiften willkiirlichen Muskulatur, Virchowx Srch. f. path. Anat. 260: 215-233, 1926. 2. Penal, F.: TJeber ein congenitales Rhabdomyom der Zunge, Ztschr. f. IIeilk. 18: 457468, 1897.
MYORLASTIC
MYOMA
49
3. Moschcowitz, El.: Xanthoma of the Tongue, Proc. New York Path. Sot. 22: 135-141, 1922. 4. Crane. A. R.. and Tremblav. R. G.: >fvoblastoma. Am. J. Path. 21: 355-3i2. 1945. 5. Simon, &I. A.: Granular Eel1 Myobla&oma,. Am.‘J. Clin. Path. 17: 302-31$ 1947. ti. Powell, E.: Granular Cell Mvoblastoma, Arch. Path. 42: 517-524, 1946. i. Hernier, .J. L.: Myoblast&a, Am. J. brthodontirs and Oral 8urg. (Oral Burg. Sect.) 33: 548-551, 194i. X. Ackerman, JA. V.: 3Ialignant Granular Cell Myoblastoma of the Gluteal R,egion, Surgery 20: 511-519, 1946. 9. Ravich, A., Stout, A. P., and Ravieh, R. A.: Malignant Granular (‘ell Myoblastorna of Urinary Bladder, Am. J. Surg. 121: 361-372, 1945. 11). Khanolkar, V. R.: Grauular (lell Myoblastoma, Am. .T. Path. 23: 721-739, 1947. 11. stout, A. P.: Granular Cell Myoblastoma of the Breast, -1. Missouri 11. A. 44: 342344? 194T. 1% Gre\-, S. H., and Gruenfeld, G. E.: Myoblastoma, Am. .T. Cancer 30: 699-708, 1937. 13. Klemperer, Paul: Myoblastoma of Mriated Muscle, Am. J. Cancer 20: 324-337, 1934. 1-I. Ewing, .l. 1%: Neoplastic Ijiseases, ed. 4, Philadelphia, 1942, \V. H. Saunders Company.
15. Xbrikossoff, A.: \Veitere TJntersuchungen ueber l\lyoblastenm~olt~e, ‘Yirchows Arch. f. path. Anat. 280: 723-740, 19X.1. Ifi. Ming:, F.: I:eber die sogenannten unreifen, nicht quergestreiften Nyoblastermyome, C erhandl. d. deutsch. path. Qesellsch. 23: 376-332, 1928. 17. Wolbach, R. B.: Centrioles and the Histogenesis of the ?iIyofibril in Tumors of Rtriated Muscle Origin, Anat. Rec. 37: 255-262, 1928. 1-L Godlewski, ‘E:.: 1)ie Entwicklung des Skelet- und Herz-mus pelgewebes der Saugethiere, Arch. f. mikr. Anat. 60: 111-156, 1902. 19. Priutr, 1). H., Cole, H’. x., and l)river: J. R.: I*Iyoblastorna, Brch. Dormat. & Syph. 55: 2!)i-L)RR, 1919.