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

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.

The Rationale for Treating the Nodule in Dupuytren's Disease

BACKGROUND

Dupuytren's disease encompasses a spectrum of fibroblastic disorders from the presence of 1-2 nodules in the palm of a hand with no joint contracture to grotesque, crippling and disabling deformities of hands. Over the last 50 years, many enlightening studies have been forthcoming, which, through techniques of histopathology, biochemistry, tissue culture, and electron microscopy, have shed pearls of light on various aspects of the disease process.

METHODS

A comprehensive review of the literature on Dupuytren's disease was undertaken, stringing together results from numerous studies to establish a table of events and their location in the development of the disease.

RESULTS

What will be seen is a credible scenario of events which will enable the clinician to be more proactive in the earlier treatment of the disease and more aware of factors that increase or decrease recurrence rates postoperatively.

CONCLUSIONS

The most effective management of Dupuytren's disease is early recognition and treatment of the nodule, before the development of a joint contracture, particularly of a proximal interphalangeal joint. As there is evidence of a significant inflammatory role in the development of the nodule, the process of fibroplasia can be minimized by altering the macrophage > fibroblast > collagen cascade by the intralesional injection of a potent anti-inflammatory agent such as triamcinolone, which also blocks tissue inhibitors of collagenase, thus enhancing the action of native collagenase, and reduces the size and firmness of nodules and, at least temporarily, arrests their 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%.

Beta-catenin overexpression in Dupuytren's disease is unrelated to disease recurrence

Recurrence of Dupuytren's contracture is common yet unpredictable, compromising surgical outcome. The alpha-smooth muscle actin-containing myofibroblast is the active contractile cellular component. Based on recent reports on beta-catenin accumulation in Dupuytren's disease, we investigated a possible relation with disease recurrence. We divided a collection of 143 nodules into those from patients with recurrent or nonrecurrent nodules and with a minimal 3-year followup. We randomly selected 12 and 11 samples of each group, respectively. We looked at Dupuytren's diathesis, immunohistologic staining for beta-catenin and alpha-smooth muscle actin, and Luck's histologic stages (zones). The expression of selected Wnt genes was examined with TaqMan PCR in separate histologic zones. All samples showed cytoplasmic and nuclear beta-catenin accumulation in myofibroblasts in involutional zones. The risk score of Abe et al. and Dupuytren's diathesis were greater in the recurrent group. Greater Wnt5a expression in the beta-catenin-accumulating involutional zone was seen. We conclude intracellular beta-catenin accumulation, possibly regulated by upstream Wnt signaling pathway activation and confined in myofibroblasts in the involutional zone of Dupuytren's diathesis, is unrelated to disease recurrence. Clinical parameters for Dupuytren's diathesis remain the best way to predict recurrence risk.

Identification of biomarkers in Dupuytren's disease by comparative analysis of fibroblasts versus tissue biopsies in disease-specific phenotypes

PURPOSE

Biomarkers are molecular mediators that can serve as indicators of normal biological processes, pathologic processes, and therapeutic interventions. This study aims to identify potential biomarkers in Dupuytren's disease (DD), a fibroproliferative benign tumor with an unknown etiology and high recurrence after surgery.

METHODS

Bioinformatic analytical techniques were employed to identify candidate genes that may be differentially expressed in DD, which included gene expression analysis of microarray data and thorough literature searches in genetic linkage and other related biomolecular studies. All DD cases were males with advanced DD (n = 5, 66 years +/- 14). RNA was extracted from biopsies and corresponding cultures of normal fascia (unaffected transverse palmar fascia), palmar nodule and cord from each patient. Real-time reverse transcription-polymerase chain reactions were performed to determine the gene expression levels for disease-related transcripts.

RESULTS

The bioinformatic analysis revealed 25 candidate genes, which were further short-listed to 6 genes via functional annotation. The 6 selected candidate genes included: A disintegrin and metalloproteinase domain (ADAM12), aldehyde dehydrogenase 1 family member (ALDH1) A1, Iroquois homeobox protein 6 (IRX6), proteoglycan 4 (PRG4), tenascin C (TNC), and periostin (POSTN). The culturing treatments were shown to have significant impact on the gene expression for ALDH1A1, PRG4, and TNC. In tissue biopsies, significant fold changes were observed for ADAM12, POSTN, and TNC in the cord and/or nodule when compared with that of normal fascia. ADAM12 and POSTN are associated with accelerated or abnormal cell growth, whereas TNC has been associated with fibrotic diseases and cell migration.

CONCLUSIONS

This study demonstrated differential gene expression results in DD tissue biopsies compared with that of their corresponding cultures. ADAM12, POSTN, and TNC were identified from the cord and nodule biopsy samples as potential biomarkers in relation to DD development.

Multinucleated giant cells in plantar fibromatosis

Specimens from 13 patients with plantar fibromatosis were reviewed with particular attention to the presence and number of multinucleated giant cells in the lesions. These were found in all specimens but one and ranged from very few to many. The nuclei of the giant cells were uniform, rounded to somewhat elongated, and arranged in circles, semicircles, ovals, clusters, chains, and V's. Aside from the giant cells, the lesions were composed of the usual uniform fibroblastic spindle cells. The growth pattern was almost always multinodular, with nodules having moderate to high cellularity. Maximal mitotic rate varied up to more than 10 mitotic figures per 10 high-power fields but was most often between 1 and 4 mitotic figures per 10 high-power fields. The patients were from 10 to 66 years of age; nine were male and four were female. Two had bilateral involvement. Five patients had recurrence, including three with multiple recurrences, and all but one of the remainder had only short follow-up. Judging from the available data, recurrence did not appear to be related to any specific clinical or pathologic feature.

Myofibroblasts of palmar fibromatosis co-express transforming growth factor-alpha and epidermal growth factor receptor

Several studies have shown that different growth factors are involved in the pathogenesis of palmar fibromatosis. The aim of the present study was to investigate whether transforming growth factor alpha (TGF-alpha) and its cellular receptor, epidermal growth factor receptor (EGF-R), are expressed in palmar fibromatosis. Nodules from 20 patients with palmar fibromatosis and control normal palmar fascias were studied by the reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. RT-PCR followed by Southern blotting demonstrated that palmar fibromatosis nodules contained high levels of TGF-alpha and EGF-R messenger RNA (mRNA) transcripts, while normal fascias showed only low levels. Depending on the degree of cellularity and fibrosis, the three following histological phases were recognized in palmar fibromatosis nodules: proliferative, involutional, and residual. Immunohistochemistry, using alpha-smooth muscle actin as a cellular marker for myofibroblasts, revealed that TGF-alpha and EGF-R are co-expressed by myofibroblasts in the highly cellular areas of both proliferative and involutional phases, while they are absent or only focally detectable in the fibroblasts of normal fascia and in hypocellular and fibrotic areas of both involutional and residual phases. The restricted co-expression of TGF-alpha and EGF-R to myofibroblasts, the proliferating cellular component of nodules, suggests that an autocrine and/or juxtacrine growth stimulation by TGF-alpha via the EGF-R may be involved in the pathogenesis of palmar fibromatosis.

A picropolychrome staining technique applied to Dupuytren's tissue

Although the histology of Duputyren's tissue is well-documented, conventional stains do not distinguish between the different types of collagen which biochemistry and immunochemistry suggest are present. Duputyren's specimens [nodules (n = 26), cords (n = 15) and dermofasciectomies (n = 6)] were stained with haematoxylin and eosin, Van Gieson's Mallory's, Masson's, and Herovici's picropolychrome stain, and examined for both cellularity and collagen staining characteristics. All stains illustrated the marked cellularity of the nodules, contrasting with a paucity of cells within the cords. The first four stains demonstrated uniformity of the collagen staining within the tissues. Herovici's picropolychrome, however, showed distinct staining patterns for the dermis, nodules and cords, with both purple/red and blue areas. Other studies suggest that those fibres stained purple/red and blue are types I and III collagens respectively. These findings may shed further light on the tissue of origin of Duputyren's disease.

Co-ordinate expression of alpha 5 beta 1 integrin and fibronectin in Dupuytren's disease

The expression of alpha 5 beta 1 (alpha 5 beta 1) integrin and its extracellular ligand fibronectin was studied immunohistochemically in 23 cases of Dupuytren's disease using an immunoperoxidase method for light microscopic visualization. All cases consisted of multiple nodules showing a variable degree of cellularity and fibrosis. Depending on the histological appearance of these nodules, each case was assigned to the three following phases: proliferative, involutional and residual. Alpha 5 beta 1 integrin was detected in the highly cellular areas of both proliferative and involutional phases where fibronectin was simultaneously expressed in the extracellular matrix (ECM). Diversely alpha 5 beta 1 and fibronectin disappeared from the hypocellular areas of involutional phase, undergoing fibrotic transformation, and from the fibrotic connective tissue of residual phases. These findings indicate that the expression pattern of alpha 5 beta 1 integrin correlates with the presence in the ECM of the corresponding ligand fibronectin during the different phases of Dupuytren's disease. We suggest that alpha 5 beta 1 integrin, linking fibronectin to stromal cells of both proliferative and involutional phases, may be involved in the contractile processes occurring in Dupuytren's disease.

Pulmonary myofibroblastic nodules with "amianthoid features"

Two consecutive publications appeared 1989 in the same number of a medical journal, which reported peculiar spindle-cell tumors with dense collagen or hyaline nodules, exclusively in inguinal lymph nodes of adults. The first series of 22 cases bore the title "Palisaded myofibroblastoma, a benign mesenchymal tumor of lymph node", the second with 6 identical cases "Intranodal hemorrhagic spindle-cell tumor with "amianthoid" fibers". The following case report deals with a similar tumorous lesion, with multiple small pulmonary nodules, without recognizable lymph node constituents.

Cytoskeletal characteristics of myofibroblasts in benign neoplastic and reactive fibroblastic lesions

The characteristics of the cytoskeleton of myofibroblasts were examined immunohistochemically in 10 extra-abdominal desmoid tumours, 3 palmar and 2 plantar fibromatoses and 5 nodular fasciitis; in the cultured cells of one desmoid tumour, and also ultrastructurally in 3 desmoid tumours. Polyclonal anti-desmin antibody reacted with the cells in 7 extra-abdominal desmoid tumours, 1 palmar fibromatosis, 1 plantar fibromatosis and 3 nodular fasciitis. Monoclonal antidesmin antibody reacted with cells in only 2 desmoid tumours. Desmin-positive spindle cells were scattered throughout these lesions. There were no marked ultrastructural differences between desmin-positive and desmin-negative desmoids. All specimens except one specimen of nodular fasciitis showed immunoreactivity for alpha-smooth muscle actin and vimentin. Muscle actin-positive cells were observed in all specimens. Cultured cells gave positive reactions with polyclonal desmin antibody as well as to vimentin antibodies and two preparations of actin antibodies, whereas the original tumour did not react with desmin antibody. The present studies suggested that the cytoskeleton of some myofibroblasts in both neoplastic and reactive lesions resembles that of smooth muscle cells.

Ultrastructure of fibroblasts in cyclosporin A-induced gingival hyperplasia

Specimens from 2 cases of gingival hyperplasia resulting from the treatment with the immunosuppressant cyclosporin A (CSGH) and 4 cases of inflamed gingiva (non-CSGH) were examined by electron microscopy with particular interest in the fibroblasts. In general, the fibroblasts in CSGH revealed the ultrastructural characteristics of active protein synthesis and secretion and less cytotoxic or degenerative changes. Some fibroblasts in the CSGH (23.8%) displayed cytological modifications comparable to so-called myofibroblasts, i.e., microfilament bands with semi-periodic dense nodes, nuclear indentations, and basal-lamina associated, cell-to-stromal junctions. Conversely, 5.9% of the fibroblasts in the non-CSGH showed these modifications. The modified fibroblasts were found most predominantly in the transitional area between inflamed and fibrous connective tissues. From these findings, it is suggested that the myofibroblastic modification in CSGH is regarded as a common morphological sign in actively proliferating fibrous tissue and may participate in the host-tissue response to the plaque-associated irritants.

Fine structural alterations in chronic Achilles paratenonitis in athletes

The fine structural alterations in chronic Achilles paratenonitis were studied in tissue samples obtained from 14 athletes, who were operated on for this complaint and from 3 patients without any history of this disease. In the chronically inflamed paratendineal tissue mainly two types of cells were identified: classic fibroblasts with a smooth and rough endoplasmic reticulum and only a few mitochondria and lysosomes and myofibroblast-like cells with cytoplasmic microfilaments 5-6 nm in diameter, a rough endoplasmic reticulum, some mitochondrias and free ribosomes. These cells represented 19% of 471 studied non-inflammatory cells. In the extracellular space there was an increased amount of fibrils regarded as either type I or type III collagen as sign of tissue repair. Especially around the myofibroblastic cells a fine granular ground substance was found. The amount of ground substance was as a rule increased in pericellular space. Due to the capacity of contraction in healing tissue the myofibroblasts apparently have a role in the clinical symptoms of chronic Achilles paratenonitis.

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.

Palmar fibromatosis (Dupuytren's contracture). Ultrastructural and enzyme histochemical studies of 43 cases

Forty three cases of palmar fibromatosis were studied by light and electron microscopy, enzyme histochemistry, and ultrastructural immunohistochemistry. By electron microscopy most of the cells composing the nodules in both the proliferative and the involutional stages were identical to myofibroblasts. The myofibroblasts in the involutional nodules often possessed microfilament aggregates probably representing contraction of micro(actin)filaments in the cytoplasm. The proliferative nodules revealed small perivascular haemorrhages and haemosiderin deposits accompanied by accumulation of macrophages and some lymphocytes; these inflammatory cells possibly secrete a certain growth factor inducing proliferation of genetically abnormal fibroblasts and myofibroblasts. Diaminopeptidase IV was detected in myofibroblasts and fibroblasts by enzyme histochemistry and ultrastructural immunohistochemistry; the enzyme may play a role in the metabolism of intercellular substances. Some perivascular mesenchymal cells, interpreted as variants of myofibroblasts, had moderate activity of alkaline phosphatase.

The current status of Dupuytren's disease

There has been little or no change in the methods of treating Dupuytren's disease in recent years. However, we are encouraged by the interest of cellular biologists and collagen chemists who have contributed to our understanding of the disease process. We can anticipate that sufficient knowledge will be gained in the near future so that surgeons can evolve a rational approach to the treatment of Dupuytren's disease.

The pathogenesis of Dupuytren's contracture: contractile mechanisms of the myofibroblasts

The role of myofibroblasts in the pathogenesis of Dupuytren's contracture was investigated by light and electron microscopic histochemical methods. Dupuytren's myofibroblasts contain an intracellular contractile mechanism that is driven by the dephosphorylation of adenosine triphosphate. Our study of calcium adenosinetriphosphatase (ATPase) activities verifies that the site of this energy system is on the myofilaments of the myofibroblasts. The degree of ATPase activity, as determined by cell counts, appeared to correlate with the residual contracture as predicted by the Legge and McFarlane Outcome Standard Formula. Further, alcian blue staining on the ultrastructural level indicates that the myofibroblasts are associated with each other and with surrounding collagen by a glycosaminoglycan matrix 300 to 1000 A thick. Collagen fibrils are attached by a similar matrix comprised of 100 A thick fibrils. The dynamic cellular architecture of the multiple adjacent myofibroblasts with their connections to surrounding collagen may be partially responsible for the residual clinical deformities seen in this disease.

A study of Dupuytren's tissue with the scanning electron microscope

This study was designed to determine if structural changes in the palmar fascia in Dupuytren's disease, as viewed by the scanning electron microscope, might provide some information about the pathogenesis of this disease. The palmar fascia from seven uninvolved hands and from 21 patients with Dupuytren's disease was examined. There were distinct differences between normal and diseased collagen. The diseased tissue showed collagen that was more tightly bound and had a shorter wave pattern. In the Dupuytren's tissue the waves were frequently in a helix, but this was never seen in the normal tissue. The most striking differences were noted in the nodule, presumably because it appears first, followed by the cord proximal to the nodule (pretendinous cord). Similar but less obvious changes were noted in the cord distal to the nodule (central cord) presumably because it is last to form. These observations suggest a mechanism of contraction. The short wave length and helix formation of the collagen indicate shortening. If the concept of the myofibroblast as a contractile cell is accepted, the contraction of these cells in stepwise fashion could produce the changes in the structure of the collagen that have been observed and result in joint contracture.

Myofibroblasts in fibrous tumors and fibrosis in various organs

The morphology and population of myofibroblasts detected by electron microscopy in fibrous tumors and fibrosis in various organs have been examined. The myofibroblast was identified by characteristic features of the indented nucleus, bundles of abundant microfilaments with dense bodies, focal basal lamina and well-developed rough endoplasmic reticulum. It has been observed that myofibroblasts in a variety of fibrous tumors and fibrosis appeared predominantly in fibromatosis and reparative process of deep fibrous tissues and organs particularly in the lesions involving the fascia and subcutaneous tissue. It was suggested that myofibroblasts would be modified fibroblasts to which fibroblasts in the fascia and deeply situated fibrous tissue transformed during proliferation and differentiation.