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Background
Myoepithelial cells possess the capacity for epithelial and myoid differentiation. Benign and malignant neoplasms of myoepithelial cells comprise a rare but well-characterized group of tumors, among which myoepithelioma of the salivary glands is the best known.
OUTLINE
Gross Appearance and Clinical Variants Histopathological Features and Variants Commonly Used Terms Internet Links
GROSS APPEARANCE/CLINICAL VARIANTS CHARACTERIZATION General VARIANTS Semin Diagn Pathol 1996;13:138–47. Myoepithelioma of salivary glands: report of 23 cases.
Sciubba JJ, Brannon RB.
Cancer 1982 Feb 1;49(3):562-72 Abstract quote
Twenty-three neoplasms arising in major and minor salivary glands have been found to be composed of two types of myoepithelial cells--the plasmacytoid and spindle-cell form.
Twelve of these were located within the parotid gland and the submandibular gland and intraoral minor salivary glands accounted for five each. A solitary example was found within the upper lip. Sixteen (70%) of the cases were of the spindle-cell type, four (17%) were composed of plasmacytoid cells, and three cases (13%) contained both cell forms in approximately equal quantity. Differences in behavior, recurrence rate, frequency, age of the patient, and location were not related to cell type. Ultrastructural analysis of selected cases showed myofilament aggregation patterns to vary between the two subtypes.
Previously published cases confirmed by electron microscopy have been reviewed and compared with the 23 cases reported. Conservative surgical management is curative. Follow-up information on 16 cases is presented.
Hum Pathol 1995;26:802–4. J Surg Oncol 1986;32:58–64. Ultrastruct Pathol 1995;19:269–74. SKIN
Division of Dermatopathology, Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
An 83-year-old Caucasian woman presented to her dermatologist with a 5-cm subcutaneous tumor on her right thigh. The lesion had been present for many years, but had recently enlarged. Incisional biopsy showed a multinodular tumor composed of variably sized glands comprised of a luminal layer of epithelial cells surrounded by one or more layers of myoepithelial cells. The histopathologic features resembled those of adenomyoepithelioma, an uncommon neoplasm usually encountered within the breast.
Primary cutaneous adenomyoepithelioma is very rare yet shares histopathologic features with common cutaneous lesions such as spiradenomas and benign mixed tumors (chondroid syringomas). Primary cutaneous adenomyoepithelioma is part of the spectrum of epithelial-myoepithelial tumors that includes benign mixed tumor, myoepithelioma and myoepithelial carcinoma.
This rare tumor may mimic malignant lesions including metastatic adenocarcinoma. Like its breast counterpart, primary cutaneous adenomyoepithelioma should probably be regarded as a neoplasm of borderline malignant potential.
- Myoepithelioma of parotid gland presenting as infra-auricular subcutaneous mass.
Lee MW, Nam SY, Choi HJ, Choi JH, Moon KC, Koh JK.
Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea.
J Cutan Pathol. 2005 Mar;32(3):240-4. Abstract quote
Myoepithelioma is a rare but well-characterized group of tumours, among which myoepithelioma of the salivary glands is the best known.
We report two patients with myoepithelioma of parotid gland presenting as infra-auricular subcutaneous mass. The lesions were clinically suspected to be epidermal cyst. The biopsies revealed that most of the tumour cells showed epithelioid features with oval or spindle eosinophilic cytoplasm. No ductal or syringomatous epithelial structures were observed. The tumour cells showed cytoplasmic immunoexpressions of vimentin, cytokeratin (AE1/AE3), S-100 protein and smooth muscle actin (SMA). In one patient, a strong calponin positivity was observed. Maguetic resonance imaging (MRI) of both patients revealed exophytic, well-defined, strongly enhancing mass in superficial lobe of parotid gland, confirming the parotid gland origin.
Myoepithelioma of parotid gland can be presented as a slowly growing tumour of pre- or infra-auricular area. In dermatologic department, it can be misdiagnosed as various dermal or subcutaneous tumours.
Cutaneous myoepithelioma: A clinicopathologic and immunohistochemical study of 14 cases.
Hornick JL, Fletcher CD.
Hum Pathol. 2004 Jan;35(1):14-24 Abstract quote.
Analogous to mixed tumors of salivary glands (" pleomorphic adenomas" ), cutaneous mixed tumors (" chondroid syringomas" ) contain a ductal (epithelial) component and a variably prominent myoepithelial component. Tumors showing purely myoepithelial differentiation (myoepitheliomas) have only recently been recognized to arise in the dermis, and to date very few cases have been described.
To characterize these tumors further, 14 cutaneous myoepithelial tumors were retrieved from the authors' consult files. Eleven patients were male and 3 were female; their median age was 22.5 years (range, 10 to 63 years), and 7 patients were between 10 and 20 years old. Tumor size ranged from 0.5 to 2.5 cm (mean, 1.1 cm). Most tumors arose on the extremities: 6 on the upper limbs, 6 on the lower limbs, and 1 each on the back and nose. Ten tumors were limited to the dermis, and 5 also extended into superficial subcutis. Thirteen tumors were myoepitheliomas (lacking ductal differentiation), and 1 tumor was a myoepithelial carcinoma (exhibiting severe cytological atypia and a high mitotic rate). Histologically, 7 tumors were solid, composed of ovoid to spindled, histiocytoid, or epithelioid cells with no significant stroma, and 7 were predominantly lobulated, with cords or nests of epithelioid, plasmacytoid, or spindled cells with a variably reticular architecture and a chondromyxoid or collagenous/hyalinized stroma. One tumor was composed solely of plasmacytoid (hyaline) cells, and 1 exhibited extensive adipocytic differentiation. Among the 13 myoepitheliomas, mitoses ranged from 0 to 6 per 10 high-power fields (HPFs) (mean, 1.5); 8 tumors contained no mitoses. The myoepithelial carcinoma had 39 mitoses per 10 HPFs.
By immunohistochemistry, all cases were reactive for epithelial markers (keratins and/or epithelial membrane antigen [EMA]); 13 of 14 (93%) expressed S-100 protein, 10 of 11 expressed (91%) calponin, 11 of 14 (79%) expressed EMA, 9 of 14 (64%) expressed keratins, 8 of 14 (57%) expressed smooth muscle actin, 7 of 14 (50%) expressed glial fibrillary acidic protein, 3 of 11 (27%) expressed p63, and 1 of 6 (17%) expressed desmin. All 5 cases without keratin staining were diffusely positive for EMA, and all of these cases showed a solid growth pattern. Follow-up was available for 8 patients (median follow-up, 40 months; range, 6 months to 9 years); 3 tumors (38%) recurred locally, and 1 tumor (13%) also metastasized to the lymph nodes. The case that resulted in recurrence and metastasis had the highest mitotic rate (6 per 10 HPFs) of the cytologically benign tumors. Follow-up information was not available for the myoepithelial carcinoma.
This study suggests that approximately 50% of cutaneous myoepitheliomas are distinctive lesions composed of a solid proliferation of cells with abundant eosinophilic syncytial cytoplasm, which often lack immunostaining for keratin, whereas the remainder demonstrate focally reticular architecture and myxoid stroma or plasmacytoid cells, similar to their counterparts in salivary gland and soft tissue. Whereas most cutaneous myoepitheliomas behave in a benign fashion, there is apparently a significant risk for local recurrence but a low metastatic potential.
Cutaneous myoepithelial neoplasms: clinicopathologic and immunohistochemical study of 20 cases suggesting a continuous spectrum ranging from benign mixed tumor of the skin to cutaneous myoepithelioma and myoepithelial carcinoma.Mentzel T, Requena L, Kaddu S, Soares De Aleida LM, Sangueza OP, Kutzner H.
Dermatopathologisches Gemeinschaftslabor, Friedrichshafen, Germany, Departments of Dermatology, Fundacion Jimenez Diaz, Universidad Autonoma, Madrid, Spain, University of Graz, Graz, Austria, Hospital de Santa Maria, Lisboa, Portugal, and Wake Forest University, Winston-Salem, NC, USA.
J Cutan Pathol. 2003 May;30(5):294-302. Abstract quote BACKGROUND: Myoepithelial neoplasms, both benign and malignant, are rare but well-established clinicopathologic entities in the salivary glands, the breast, and the lung. Despite similarities between cutaneous sweat glands and glandular structures in the above-mentioned organs as well as the presence of regular myoepithelial cells around cutaneous eccrine/apocrine glands, the concept of cutaneous myoepithelial neoplasms is still debatable and not commonly accepted.
METHODS: Twenty cutaneous myoepithelial neoplasms have been studied histologically and immunohistochemically.
RESULTS: Nine neoplasms showed features of benign mixed tumor of the skin (chondroid syringoma) (five females and four males, age range 19-65 years, all cases arose in the head and neck region). Two cases represented the eccrine and seven the apocrine subtype. Interestingly, in three cases of the apocrine subtype, solid areas composed predominantly of myoepithelial cells were detected; these neoplasms were designated as benign mixed tumors with prominent myoepithelial cells. Nine cutaneous neoplasms were composed of spindled, epithelioid, and plasmocytoid cells without ductal differentiation and immunohistochemically stained variably positive for vimentin, epithelial and myogenic markers, S-100 protein, calponin, and glial fibrillary acidic protein (four females and five males, age range 3-71 years, four cases arose in the head and neck region and one case each on the finger, the thigh, the lower leg, the foot, and the breast, respectively); these neoplasms were designated as cutaneous myoepitheliomas. Two morphologically malignant neoplasms with cytologic and immunohistochemical features of myoepithelial cells arose on the face of a 70-year-old female and a 79-year-old male patient; these neoplasms were designated as malignant cutaneous myoepitheliomas (cutaneous myoepithelial carcinomas).
CONCLUSIONS: The study suggests a continuous spectrum of cutaneous myoepithelial neoplasms ranging from benign mixed tumor of the skin to cutaneous myoepithelioma and cutaneous myoepithelial carcinoma. Further studies with extended follow-up information are necessary to establish prognostic factors.SOFT TISSUE
Myoepithelial tumors of soft tissue: a clinicopathologic and immunohistochemical study of 101 cases with evaluation of prognostic parameters.
Hornick JL, Fletcher CD.
Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
Am J Surg Pathol. 2003 Sep;27(9):1183-96. Abstract quote
Myoepitheliomas and mixed tumors were only recently recognized to occur primarily in soft tissue, and only small case numbers have been described.
To characterize these tumors further and to evaluate prognostic parameters, 101 myoepithelial tumors of soft tissue were retrieved from the authors' consult files. Hematoxylin and eosin sections were reexamined, immunohistochemistry was performed, and clinical details were obtained from referring physicians. Fifty-three patients were male and 48 female (mean age 38 years; range 3-83 years). Tumor size ranged from 0.7 to 20 cm (mean 4.7 cm). Most tumors arose in the extremities and limb girdles: 41 in the lower limbs, 35 in the upper limbs, 15 in the head and neck, and 10 in the trunk. Fifty-four tumors were situated in subcutis and 37 in deep soft tissue (depth unstated in 10).
Most cases were grossly well circumscribed; 43 showed microscopically infiltrative margins. Histologically, most tumors were lobulated, composed of cords or nests of epithelioid, ovoid, or spindled cells with a variably reticular architecture and a chondromyxoid or collagenous/hyalinized stroma. Eight cases showed a predominantly solid proliferation of spindled or plasmacytoid cells; 17 demonstrated ductular differentiation (mixed tumors). Cartilage was present in 6 cases, 6 contained bone, and 4 others contained both. Mitoses ranged from 0 to 68 per 10 high power fields (mean 4.7 per 10 high power fields). Tumors with benign cytomorphology or mild cytologic atypia (low-grade) were classified as myoepithelioma or mixed tumor, whereas tumors with moderate to severe atypia (high-grade) were classified as myoepithelial carcinoma (epithelioid or spindled cells with vesicular or coarse chromatin, prominent, often large nucleoli, or nuclear pleomorphism) or malignant mixed tumor (cytologically malignant cartilage or bone). Sixty-one cases were myoepitheliomas or mixed tumors, and 40 were myoepithelial carcinomas or malignant mixed tumors.
By immunohistochemistry, all cases with available material were reactive for epithelial markers (keratins and/or epithelial membrane antigen): 90 of 97 (93%) expressed keratins (most often AE1/AE3 or PAN-K), 84 of 97 (87%) S-100 protein, 44 of 51 (86%) calponin, 52 of 83 (63%) epithelial membrane antigen, 40 of 87 (46%) glial fibrillary acidic protein, 27 of 75 (36%) smooth muscle actin, 15 of 66 (23%) p63, and 7 of 51 (14%) desmin. Follow-up was available for 64 patients. Among 33 cases with benign or low-grade cytology (mean follow-up 36 months; range 4-168 months), 6 recurred locally (18%) and none metastasized. No clinical or histologic features correlated with recurrence. Among 31 cytologically malignant cases (mean follow-up 50 months; range 4-252 months), 13 recurred locally (42%) and 10 metastasized (32%); so far, 4 patients have died of metastatic tumor.
This study expands the spectrum of myoepithelial tumors of soft tissue to include myoepithelial carcinomas and malignant mixed tumors, which pursue an aggressive clinical course. Although the majority of morphologically benign or low-grade myoepithelial neoplasms of soft tissue behave in a benign fashion, there is an approximate 20% risk for local recurrence.Mixed tumors and myoepitheliomas of soft tissue: a clinicopathologic study of 19 cases with a unifying concept.
Kilpatrick SE, Hitchcock MG, Kraus MD, Calonje E, Fletcher CD.
Department of Pathology, North Carolina Baptist Hospitals, Bowman Gray School of Medicine, Winston-Salem, U.S.A.
Am J Surg Pathol 1997 Jan;21(1):13-22 Abstract quote
We report 19 unusual cases of mixed tumors and myoepitheliomas arising in soft tissues. The neoplasms occurred in 12 males and seven females. The age at diagnosis ranged from 2 to 83 years (mean 35, median 30). Eight tumors arose in the upper limb, six in the lower limb, three in the trunk, and two in the head and neck region. Three cases involved both dermis and subcutis; the remainder arose in subcutaneous (13 cases) or deep subfascial soft tissue (three cases). The most common presenting complaint was a painless swelling, with duration ranging from 2 weeks to 1 year (median 2.5 months).
Microscopically, the tumors were predominantly well circumscribed and lobulated. Six cases showed a focally infiltrative margin. Cardinal morphologic features included nests, cords, and ductules of epithelioid cells and/or nests of spindled cells within a hyalinized to chondromyxoid stroma. One tumor was predominantly composed of myoepithelial cells and devoid of epithelial differentiation (i.e., ductules). Cytoplasmic hyaline inclusions were noted in two cases; squamous differentiation was seen in one case. Osteoid production and/or metaplastic bone was observed in three tumors. Chondroid differentiation (usually mature) was seen in four cases. Adipocytic differentiation was seen in two tumors. Mitotic activity was variable but generally scant; atypical mitotic figures were not identified. By immunohistochemistry, 16 of 16 cases expressed pan-keratin; 16 of 17 S-100 protein; six of 14 alpha smooth muscle actin (IA4); two of 10 muscle specific actin (HHF-35); two of 10 desmin; three of 11 glial fibrillary acidic protein; and three of 16 epithelial membrane antigen. Clinical follow-up was available in 10 patients and ranged from 6 months to 20 years (mean 4.25 years, median 2 years). Two patients developed local recurrence; metastasis to lung and lymph nodes were observed in two additional patients. Both of the latter patients died.
We believe that these findings expand the concept of cutaneous mixed tumors to include neoplasms composed predominantly of myoepithelial cells and to include tumors arising in deeper subcutaneous and/or subfascial tissues. The clinical behavior of such neoplasms, when arising in soft tissues, may be difficult to predict but is most often benign; however, a minority of lesions metastasize. Until larger studies with longer follow-up are available, treatment and prognostication are probably best based on criteria used in comparable salivary gland tumors.
Macpherson and Pincus. Clinical Diagnosis and Management by Laboratory Methods. Twentyfirst Edition. WB Saunders. 2006.
Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.
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