Occurrence of myofibroblasts in the different phases of morbus Dupuytren (Dupuytren's contracture)

Inflammatory Markers Involved in the Pathogenesis of Dupuytren's Contracture

Dupuytren's disease is a common fibroproliferative disease that can result in debilitating hand deformities. Partial correction and return of deformity are common with surgical or clinical treatments at present. While current treatments are limited to local procedures for relatively late effects of the disease, the pathophysiology of this connective tissue disorder is associated with both local and systemic processes (e.g., fibrosis, inflammation). Hence, a better understanding of the systemic circulation of Dupuytren related cytokines and growth factors may provide important insights into disease progression. In addition, systemic biomarker analysis could yield new concepts for treatments of Dupuytren that attenuate circulatory factors (e.g., anti-inflammatory agents, neutralizing antibodies). Progress in the development of any disease modifying biologic treatment for Dupuytren has been hampered by the lack of clinically useful biomarkers. The characterization of nonsurgical Dupuytren biomarkers will permit disease staging from diagnostic and prognostic perspectives, as well as allows evaluation of biologic responses to treatment. Identification of such markers may transcend their use in Dupuytren treatment, because fibrotic biological processes fundamental to Dupuytren are relevant to fibrosis in many other connective tissues and organs with collagen-based tissue compartments. There is a wide range of potential Dupuytren biomarker categories that could be informative, including disease determinants linked to genetics, collagen metabolism, as well as immunity and inflammation (e.g., cytokines, chemokines). This narrative review provides a broad overview of previous studies and emphasizes the importance of inflammatory mediators as candidate circulating biomarkers for monitoring Dupuytren's disease.

Targeting Myofibroblasts as a Treatment Modality for Dupuytren Disease

PURPOSE

Currently, no treatment corrects the contractile nature of Dupuytren myofibroblasts (DMFs) or prevents recurrence following surgery. Antifibrotic and proadipogenic growth factors are released when adipose-derived stem cells (ASCs) are cultured with platelet-rich plasma (PRP), a platelet concentration from whole blood. Reprograming myofibroblasts into adipocytes via growth factors is proposed as a powerful potential tool to target fibrosis. We aimed to assess whether the combination of ASCs and PRP reprograms DMFs into adipocytes in vitro and alters their contractile nature in vivo.

METHODS

Normal human dermal fibroblasts (NHDFs) and DMFs from Dupuytren patients were isolated and cocultured with ASCs and PRP either alone or together. Adipocytes were detected by Oil Red O and perilipin staining. DMFs and NHDFs were transplanted into the forepaws of rats (Rowett Nude [rnu/rnu]) and treated with saline, PRP+ASCs, or collagenase Clostridium histolyticum (clinical comparison) 2 months later. After 2 weeks, the tissue was harvested and subjected to Masson trichrome staining, and collagen I and III and alpha-smooth muscle actin detection by immunohistochemistry.

RESULTS

Myofibroblasts transform into adipocytes upon coculture with PRP+ASCs. DMFs show increased alpha-smooth muscle actin expression in vivo compared with NHDFs, which is significantly decreased after PRP+ASCs and collagenase Clostridium histolyticum treatments. DMFs induce collagen I and III expressions in rat paws compared with NHDFs, with a type III to I ratio increase. Treatment with PRP+ASC reduced the ratio, but collagenase Clostridium histolyticum did not.

CONCLUSIONS

Treating DMFs with PRP+ASCs provides factors that induce myofibroblast to adipocyte transformation. This treatment reduces the contractile phenotype and fibrosis markers in vivo. Future studies should detail the mechanism of this conversion.

CLINICAL RELEVANCE

The combination of PRP and ASCs to induce the differentiation of DMFs into adipocytes may serve to limit surgery to a percutaneous contracture release and biological injection, rather than a moderate or radical fasciectomy, and reduce the recurrence of Dupuytren contracture.

Fibroproliferative disorders and diabetes: Understanding the pathophysiologic relationship between Peyronie's disease, Dupuytren disease and diabetes

Introduction

Fibrosis is characterized by dysregulation and accumulation of extracellular matrix. Peyronie's disease and Dupuytren disease are fibroproliferative disorders of the tunica albuginea of the penis and fascia of the hand, respectively. Chronic hyperglycaemia due to diabetes mellitus can also lead to tissue injury and fibrosis. A meta-analysis has shown a relationship between Dupuytren disease and diabetes (overall odds ratio, 3.1; 95% confidence interval, 2.7-3.5). This review explores commonalities in the pathogenesis of Peyronie's disease, Dupuytren disease and diabetes.

Methods

A search of the PubMed database was conducted using the search terms "diabetes" AND "Peyronie's disease"; and "diabetes" AND "Dupuytren."

Results

Genome-wide association and gene expression studies conducted with tissue from people with Peyronie's disease or Dupuytren disease identified signalling pathways associated with wingless-type mammary-tumour virus integration site signalling, extracellular matrix modulation and inflammation. Biochemical studies confirmed the importance of these pathways in the pathogenesis of fibrosis with Peyronie's disease and Dupuytren disease. Dysregulation of matrix metalloproteinase activity associated with extracellular matrix breakdown was implicated in fibroproliferative complications of diabetes and in the aetiology of Peyronie's disease and Dupuytren disease. A notable percentage of people with diabetes have comorbid Peyronie's disease and/or Dupuytren disease.

Conclusions

Studies have not been performed to identify fibroproliferative pathways that all 3 conditions might have in common, but data suggest that common pathways are involved in the fibroproliferative processes of Peyronie's disease, Dupuytren disease, and diabetes.

Myofibroblasts in Palatal Wound Healing: Prospects for the Reduction of Wound Contraction after Cleft Palate Repair

The surgical closure of orofacial clefts is considered to impair maxillary growth and dento-alveolar development. Wound contraction and subsequent scar tissue formation, during healing of these surgical wounds, contribute largely to these growth disturbances. The potential to minimize wound contraction and subsequent scarring by clinical interventions depends on the surgeon’s knowledge of the events responsible for these phenomena. Fibroblasts initiate wound contraction, but proto-myofibroblasts and mature myofibroblasts are by far the most important cells in this process. Myofibroblasts are characterized by their cytoskeleton, which contains alpha-smooth-muscle actin. Additionally, their contractile apparatus contains bundles of actin microfilaments and associated contractile proteins, such as non-muscle myosin. This contractile apparatus is thought to be the major force-generating element involved in wound contraction. After closure of the wound, the myofibroblasts disappear by apoptosis, and a less cellular scar is formed. A reduction of contraction and scarring might be obtained by inhibition of myofibroblast differentiation, stimulation of their de-differentiation, stimulation of myofibroblast apoptosis, or impairment of myofibroblast function. In this review, we will discuss all of these possibilities, which ultimately may lead to a better outcome of cleft palate surgery.

Occurrence of Myofibroblasts in Recurrent Dupuytren’s Disease

Surgically removed nodules from ten patients with recurrent Dupuytren’s disease were studied by electron microscopy. Myofibroblasts were found in eight cases in the active (involutional) stage. The distinctive ultrastructural features were similar to those of the original Dupuytren’s disease. We believe that, in addition to other factors, myofibroblasts have a non-specific but important role in the pathology of recurrent Dupuytren’s disease.

A review of the classification of Dupuytren's disease

Although much has been published about the treatment of Dupuytren's disease, there is no clear consensus regarding the most effective form of treatment. Part of this uncertainty may result from the absence of a universal method of assessing this condition. We undertook a review of the literature in order to summarize the various methods by which Dupuytren's disease has been measured and quantified. We included all articles that offered a classification or assessment system for the disease. We excluded articles that dealt solely with surgical technique (although inevitably there was some overlap). We conclude that there are many methods of assessment, but that none of them is perfect and that further work is needed in the field.

Carcinoma-associated fibroblasts, its implication in head and neck squamous cell carcinoma: a mini review

The communication between tumor stromal and parenchymal cells provides an insight to tumor progression. One of the main elements of the stroma, a major contributor to the extracellular environment of tumors, is carcinoma-associated fibroblasts. They can originate from either normal fibroblasts in the immediate vicinity of the tumor or from circulating bone marrow-derived mesenchymal stem cells. These myofibroblasts can arise locally from an endothelial-mesenchymal transformation at the invasive edge of the cancer and are physically associated with carcinoma cells, that is, in the development of high-grade malignancies and poor prognosis. These carcinoma-associated fibroblasts feed the epithelial tumor cells in a host-parasite relationship establishing its role in head and neck squamous cell carcinoma progression.

Re-visiting Luck's classification: a histological analysis of Dupuytren's disease

Luck (1959) described a histological staging system for Dupuytren's disease, classifying the disease into three stages. Previous biochemical and immunochemical studies have detailed the decrease in type III/I collagen ratio with disease progression. Herovici (1963) described a histological stain that produced a differential red/purple and blue colour for type I and III collagen respectively. We stained 15 specimens of Dupuytren's disease and quantified the different collagen types in each using computer analysis. We found a corresponding decrease in the amount of type III collagen as a percentage of the total collagen with disease progression: stage I range 35-49% (mean 38%); stage 2 range 21-33% (mean 27%) and stage 3 range 11-19% (mean 14%). We propose a new staging system based on the relative amount of type III collagen, where stage 1: >35%, stage 2: >20% and <35%, and stage 3: <20%.

New insights in the development of Dupuytren's contracture: a review

Recent advances in the understanding of myofibroblast histology and function, the activity of fibrogenic cytokines, the role of the extracellular matrix and of free radicals are contributing to an understanding of the aetiology of Dupuytren's disease but not yet to its treatment. Surgical excision remains the best treatment.

Contraction of collagen lattices by cells from Dupuytren's nodules

The aim of this study was to see if nodular cells in Dupuytren's disease differed from dermal cells in their contractile capacity and motility. Ten surgical specimens from patients with Dupuytren's disease and contracture of the finger of more than 45 degrees were harvested and the nodular cells were explanted and cultured. Dermal fibroblasts from the forearm were used as control cells. Both types of cell had the same growth pattern. The morphology on confocal laser scanning microscopy was also similar in both types of cell. Dermal control cells caused significantly more contraction of collagen lattices compared with fibroblasts from nodules of Dupuytren's contracture. The F-actin content was equal in both groups. Platelet derived growth factor, PDGF-BB (but not PDGF-AA), increased the chemotactic activity of both cell types, but there were no differences between them. The results indicate that at a late state of the disease cells from Dupuytren's nodules lose their contractile capacity and regain a phenotype resembling that of dermal fibroblasts.

An investigation into the role of inflammatory cells in Dupuytren's disease

An immunohistochemical study was performed on nodules excised from the palmar fascia of patients with Dupuytren's contracture. In cellular nodules, antibodies to actin (used as a marker for myofibroblasts), desmin, vimentin, Mac 387 (a macrophage marker) and leucocyte common antigen were used. A correlation was demonstrated between the numbers of macrophages and the presence of myofibroblasts. The presence of myofibroblasts is generally considered to indicate the active stage of the disease. Inflammatory cells other than macrophages were largely absent from the nodules, although lymphocytes were frequent in the tissue around the nodules. Microvascular changes were prominent in the nodules and pericyte proliferation was observed around occluded capillaries. Release of growth factors from macrophages may be important in Dupuytren's contracture, as is the case in other fibrotic diseases. The possible role of macrophages in the aetiology of Dupuytren's disease is discussed.

Prediction of recurrence in the treatment of Dupuytren's disease: evaluation of a histologic classification

Histologic staging of Dupuytren's lesions into three types is proposed: a proliferative type with high cellularity and mitosis, a fibrocellular type characterized by the presence of a reticulin network, and a fibrous type with few cells. Sixty-three patients (77 hands) who had selective fasciectomy as a primary procedure and whose histologic specimen was available were clinically reviewed for disease recurrence and extension. Twenty-two hands (29%) were free of disease; twenty-five (32%) were free from recurrence but showed an extension, and thirty (39%) had a recurrence. This histologic classification seems to have a prognostic value because the recurrence rate is higher in type I (70%) and lower in type III (18%). The risk of extension did not correlate with the histologic type.

Possible role of plasminogen activator content of the palmar nodules in recurrence of Dupuytren's contracture

Increased amounts of plasminogen activator enzymes were found in the large Dupuytren's nodules in the so-called active phase of the disease. A prospective study in 15 patients who had operations investigated possible relationships between fibrinolytic capacity of the palmar nodules (assessed by the fibrin plate method) and the recurrence of contracture. There were substantial analogies and suggestive connections with the results of previous electron microscopic studies. Combined with the presence of myofibroblasts, the high increase of plasminogen activator enzymes in the fascial nodules may be regarded as a predictive marker for possible recurrence after surgical treatment of Dupuytren's contracture.

Myofibroblasts in fibromatoses. An electron microscopic study

Fifteen cases of fibromatoses were analyzed by electron microscopy, the objective being to compare the incidence and frequency of myofibroblasts in each category. Myofibroblasts were identified in all 15 cases and a considerably large number of these cells appeared in palmar fibromatosis, plantar fibromatosis, and nodular fasciitis. In keloid and cicatricial fibromatosis, however, only a small number of these cells were evident. In seven cases of extra-abdominal desmoid fibromatosis, the frequency of myofibroblasts in the component cells ranged from 10% to 64%, with a mean of 30%. The frequency was high in hypercellular lesions and low in hypocellular lesions, assuming that it would be roughly in parallel to the cellularity of the lesion in extra-abdominal desmoid fibromatosis and in other fibromatoses as well. There appeared to be no particular correlation between the number of myofibroblasts and recurrence of the lesion.

Dupuytren type fibromatoses. A clinicopathologic study of 62 cases

This clinicopathologic study concerns 62 patients with one of the Dupuytren type fibromatoses. Of the 62 patients, 42 had the lesion in the palm (palmar fibromatosis), 12 in the sole (plantar fibromatosis), 2 in the penis (penile fibromatosis), and 6 in the ectopic locations, the dorsal aspect of the hand in 3 patients, the dorsum of the fingers in 2, and the forearm in 1. The clinically palpable nodules were histologically classified into those of the following three phases, according to LUCK'S classification: proliferative phase (27), involutional phase (23), and residual phase (12). In addition to fibroblastic proliferation, the lesion of the proliferative phase exhibited vascular features consisting of one or more layers of cells with oval nuclei around the vessels within the nodule. In the lesions of the late proliferative and involutional phase, the intracytoplasmic fine filaments were visible in cells compatible with myofibroblasts by Masson's trichrome stain. The nuclei of the elemental fibroblasts in the same phases were often crossed transversely by one or more fine basophilic lines.

Dupuytren's disease: comparative growth dynamics and morphology between cultured myofibroblasts (nodule) and fibroblasts (cord)

The excised palmar fascia of 11 patients with Dupuytren's disease was separated clinically into nodules and cords. Myofibroblasts were seen by light and electron microscopy in each of the nodules, but the cords generally lacked myofibroblasts. Only one cord specimen had microscopic features that were intermediate between nodule and cord. Electron microscopy demonstrated that in vivo differences between myofibroblasts from nodules and fibroblasts from cords and control skin samples could be preserved in vitro. Growth studies showed slower growth of cultured myofibroblasts (mean +/- SD generation time 68.7 +/- 15 h) than cord-derived fibroblasts (mean +/- SD generation time 51.5 +/- 0.9 h). These data suggest that the life cycle of the myofibroblasts from Dupuytren's disease nodules differs from that of fibroblasts found in cordlike tissues. These myofibroblasts have biological characteristics nearly identical to those of myofibroblasts found in other contracting tissues, such as granulating wounds and breast cancer.

Inclusion body myofibroblasts other than those seen in recurring digital fibroma of childhood

Four patients of the toxic oil epidemic syndrome (TOES), which took place in Spain in 1981, showed a dermohypodermal fibroblastic process with round eosinophilic cytoplasmic inclusions (ECI) in the proliferating cells. Light and electron microscopic studies revealed that those cells had myofibroblastic features and that the ECI were identical to those seen in recurring digital fibroma of childhood (RDFC). Two cases of RDFC, involving the fingers of 6-month-old and 2-year-old patients, were examined by light and electron microscopy for comparative study. The 4 patients of TOES, aged 14 to 46 years, showed generalized sclerodermalike skin changes, and skin biopsies were obtained from the anterior wall of the abdomen and retromaleolar region of the left leg. The ultrastructural study of the ECI and the initiating changes leading to them allowed us to suggest a cytoskeletal origin for these inclusions.

The glycosaminoglycans of Dupuytren's disease

The total and individual glycosaminoglycan (GAG) content at various stages of the Dupuytren disease process and in samples of normal palmar connective tissue (palmar dermis, palmar fascia and digital flexor tendon) from the hands of uninvolved age-matched controls have been assayed and compared. Morphological comparisons between the different tissues were made by histological examination of sections stained to demonstrate collagen fiber patterns and glycosaminoglycan distribution. Significant differences in the type and amount of GAG were found between the various manifestations of the disease process, i.e., nodules, cellular and fibrous bands, and between these and the normal palmar connective tissues. In the most actively proliferating cellular regions chondroitin sulfate levels were 11 times greater than those of the normal palmar connective tissues, whereas dermatan sulfate tissue levels showed a fourfold increase. On the other hand, tissue concentrations of hyaluronate were similar to those of normal palmar connective tissue. The relationship of these differences in GAG levels to the development and maturation of the normal palmar connective tissues and the Dupuytren's process is discussed.

Palmar fibromatosis-"Dupuytren's contracture". A comparison of light electron and immunofluorescence microscopic findings

A comparison of light, immunofluorescence and electron microscopic findings in palmar fibromatosis (Dupuytren's disease) revealed that the three morphologic phase of Luck; I. proliferative, 2. involutional, and 3. residual, corresponded for the most part to I. fibroblastic, 2. myofibroblastic or 3. fibrocytic lesions, respectively. The spectrum between proliferative phase and residual phase appeared immunohistochemically as a decrease in collagen type III, and an increase of collagen type I. Myosin was found in substantial quantities only during the involutional phase, distinguished by myofibroblasts, presumably with contractile capabilities. Thus, the clinical presence of contractures with palmar fibromatosis might also be explained in the absence of distinct fiber formation.

[Fibrous capsule formation after augmentation mammaplasty. Experimental study (author's transl)]

The reaction of X-rays on the incapsulation of subcutaneous implantation of silastic prosthesis and further development of the capsules was studied in an experimental investigation on the basis of 14 rabbits. An influence of X-rays on type and thickness of the capsule as well as constrictive fibrosis was not ascertained. On account of our histological investigations we may say that the cause for a fibrous capsule formation is a similar process which causes Dupuytren's contracture.

Ultrastructural evidence of myofibroblasts in pseudomalignant myositis ossificans

Seven cases of pseudomalignant ossifying myositis with a typical clinical symptomatology have been reported. None of the cases had experienced an injury. All the lesions were intramuscular and all of them showed a zonal arrangement. Electron microscopy in three cases allowed the demonstration of cells showing morphological features of myofibroblasts and monocytic cells of the macrophage type. These previously unreported features together with the zonal pattern of the lesions indicate their reparative nature.