Zaman Muscle Pathology Review the normal structure and function of the myocyte and neuromuscular junction.

Motor units o o Motor neuron, peripheral axon, distal neuromuscular junction and skeletal muscle. 100-200 myofibers innervated by the same motor neuron and all in the unit are of the same type (type I or II). Therefore, histochemical type is determined by the nerve supply. Myosite = Muscle cells. Composed of myofibrils.

Myofibrils are in turn, made up of sarcomeres

Dystrophin Central member of the dystrophin glycoprotein complex connects the actin cytoskeleton with the muscle fiber membrane and its external environment.

Describe the procedure for muscle biopsy Must have a rational Ddx Ddx is important to determine procedure and studies to be done. Also time, which muscle, number of specimens and handling. 2 types of specimens o o Fresh Histo studies in all patients and immunofluorescence in selected patients. Fixed In formalin routine microscopy and EM reserved for special situations. Sample is removed using Rayport clamp i.e Used to evaluate patients with neuromuscular disease and occasionally to assess pts with myopathy. It is also involved in the diagnosis of neuropathic disease, mainly in the distinction of an atypical neurogenic disorder from a primary myopathic one. Studies in a frozen sample include, in addition to H&E

NADH, Myofiber stains (ATPase, type I and II), mitochondrial stain (Gomori), PAS (glycogen/vessels), Fat stain (Sudan black, oil red, O lipids, metabolic, mitochondria and myofibers fresh specimens used).

Paraffin sections are usually stained with H&E longitudinal and cross section. o Useful for evaluating inflammation, myopathies and vasculitis i.e processes with non-uniform distribution. o Stains Organism stains Elastic stains (vasculitis) Immunohistochemistry inflammatory cells FISH Viruses Congo red or thioflavin S Amyloid (MC)

Indications for Biopsy *** o Myopathies Including inflammatory (tx can alter histopathology findings, so is best before tx if risk is high enough to justify it. Repeat biopsy is indicated to evaluate pt with known inflammatory myopathy whos still weak after steroid therapy. o Other disorders with therapeutic options less definitive than those for inflammatory myopathies. i.e palliative tx, clinical trials, genetic counseling, prognosis. o One common indication is to distinguish between myopathy and neuropathy. Classic presentations are distinct but in practice, their H&P and lab findings often overlap. They can also coexist, making dx more difficult.

Not indicated in o o o o Dystrophinopathies Genetic testing is more commonly used. Myotonic dystrophy genetic testing. Periodic paralyses genetic Endocrine myopathies (i.e cortisol deficiency can dx with electrodiagnostic work up vs biopsy). Labs CK Useful but not definitive in differentiation neuropathy vs myopathy. >1000 = muscle disease, 200-600 = either but less likely in myopathy patients. Serum aldolase More helpful in dx myopathy. Longer half life in serum vs CK therefore more dx when CK is normal. o Electrodiagnosis Helpful to determine if disease is neuropathic, myopathic or mixed. Changes in N conduction and muscle AP Neurogenic. Shows different findings in neurogenic vs myopathic disorders. Avoid in muscle that will undergo biopsy it damages muscle and will affect biopsy interpretation for 1-2 months. If pt has suspected myopathy, needle EMG should be done one only 1 side.

Other diagnostic means o

Basic Pathological Changes Limited response to injury Atrophy and myonecrosis. Denervation causes mainly o o Atrophy due to denervation lose tone and disuse. Change in pattern of histochemical staining. Segmental with infiltration of macrophages and necrotic destruction. Necrosis and regeneration proceed together with one or the other prevailing, depending on the disease. o o Regenerating muscle are slender, basophilic and have central rows of large nuclei. Over a long period of time it will cause loss of muscle. Remaining myofibers are hypetrophic and have structural abnormalities (internal nuclei, internal splits and irregular orientation of myofilaments). Lost muscle is replaced by adipose tissue and collagen. o Inflammatory myopathies are characterized by myofiber necrosis and inflammation. Etiology is identified from type or fiber affected, muscle distribution and specific morphology. Types Disuse/Endocrine related atrophy Atrophy o o

Myonecrosis o o

Caused by prolonged bed rest/immobilization. Profound atrophy Type II fibers mainly affected. Random atrophic fiber distribution vs. grouping. MC in proximal vs. distal muscle groups.

Describe how type I & II fibers are distributed in normal muscle & in denervation atrophy. Type I One fat slow red OX o Use fat as primary source of energy, they are slow twitch fibers and undergo mitochondrial oxidative phosphorylation. Red = dark fibers. Type II Fast twitch o Opposite type I 2 subtypes, a and B 2a Intermediate between I and II 2b energy for restoration of ATP and creatine phosphate is derived from anaerobic glycolysis.

ATPase stain showing histo staining of type I and II fibers (checkerboard).

Motor neurons innervate one type or the other. They will innervate multiple muscle fibers and they are usually randomly scattered in a checkerboard pattern with a circumscribed area within the larger muscle. Denervation Atrophy o Causes distal weakness and atrophy with muscle fasciculations. Both fiber types involved. **After reinnervation fibers cluster instead of having the normal checkerboard distribution.

Name the conditions that cause denervation atrophy & describe the microscopic & histochemical findings. Causes o o o o o Caused by peripheral neuropathies and MN diseases. MCC is ALS in adults MCC in kids is autosomal recessive spinal muscular atrophy. Other causes include Polio and west Nile virus. Idiopathic Arthrogryposis multiplex congenital severe wasting or absence of muscles and contractures present at birth. Micro and Histochemical findings o Fibers cluster into groups. In the process there is loss and disarray of myofilaments but no myonecrosis.

Nuclear clumps in H&E sections Common in neurogenic atrophy (severe R). Angulated atrophic fibers at the center (L) characteristic of Neurogenic.

NADH Stains angular fibers (R). Describe the pathogenesis of Duchenne, Becker, limb-girdle & other dystrophies. Muscular Dystrophies Group of inherited disorders presenting in childhood. Characterized by progressive degeneration** of muscle fibers leading to muscle weakness and wasting. i.e 2yo cant walk and gets worse over the years. The kid gives up walking and becomes restless and crying. Histo o Muscle fibers are replaced by fibrofatty tissue Distinguishes dystrophies from myopathies Endstage. o Key pathology of DMD and BMD is myonecrosis early. Necrotic fibers are homogeneous and eosinophilic.

Duchennes and Beckers Muscle Dystrophy. o Histo Myonecrosis and degeneration seen. Myophagocytosis, marked variation in muscle fiber size caused by concomitant myofiber hypetrophy and atrophy. Regeneration including basophils, nuclear enlargement and nucleolar prominence. Fiber splitting and myonecrosis.

Necrosis of balloon cells, fiber splitting in half and loss of striation.

Definitive Dx is based on dystrophin ID Biopsy + genes DMD No Dystrophin by immunohistochemistry or western blot More severe. BMD Diminished amounts of an abnormal molecular weight dystrophy.

More Dx

Normal vs. Duchenne with dystrophin immunohistochemical test on frozen section AB stain to dystrophin. Advanced DMD Increased endomysial CT, fat infiltrates forming fibrous scar. Causes stiffness and contractures.

DMD and BMD are caused by abnormalities in dystrophin genes in the short arm of chromosome Xp23. DMD More severe than BMD and abnormalities begin in childhood. At an early stage, some muscles, especially calves appear large (Pseudoypetrophy) due to compensatory

hypetrophy of normal myofibers and increased fat (myonecrosis and regeneration. More muscle is lost as disease progresses. BMD Symptoms begin later in life and the disease is more protracted. Some patients have a nearly normal lifespan. Mutations can cause dilated cardiomyopathy and can be fatal. 20-40% of females with dystrophin mutations have mild muscle disease or dilated L ventricle. Limb Girdle Dystrophy o o o MC in the proximal musculature of trunk and limbs (like X-linked dystrophies). 6 dominant and 10 recessive subtypes (90% LGMDs). Less frequent vs. dystrinopathies and are milder. Begin in adolescence or adulthood and have a slower progression. o A subset known as Severe Childhood Autosomal Recessive Muscular Dystrophy (SCARMD) is almost as severe as Duchennes. Discuss the genetics and key pathological changes of myotonic dystrophy. o Genetics Autosomal Dominant Transmitted from the mother. 2 genetic forms DM1 Distal weakness. CTG trinucleotide expansion of the DMPK (dystrophin myotonica protein kinase) on chromosome I9q13. Lots of repeats, the more repeats the earlier the onset of sxs. Repeats increased with generations. DM2 Proximal weakness. Caused by a CCTG expansion of ZNF9 (Zinc finger protein 9) gene on 3q21. Protein disorder. Weakness, stiffness more pronounced in facial and distal muscles. Atrophy and weakness of facial muscles, ptosis and frontal baldness. Characteristic facial appearance. Myotonia (spasms) occur spontaneously or elicited by mild stimulation. Pt wont let go of your hand. May have cataracts, arrhythmias, testicular atrophy and diabetes. Progressive weakness. o Pathological changes Biopsy shows atrophy of type I fibers, profusion of central nuclei (normally they are under sarcolemma) and ring fibers. None of the changes are diagnostic alone but combination strongly suggests myotonic dystrophy. Patients are in wheel chairs by age 12 and death occurs at end of 2 nd decade respiratory insufficiency and other complications. o

NADH stain Ring fibers. Myofibrils at periphery are circumferential instead of longitudinally in the muscle cell.

Describe 3 congenital myopathies & discuss the differential diagnosis of neonatal hypotonia. o Most frequent these dystrophies are of Laminin a2. Other groups are caused by mutations of enzymes that glycosylate alpha dystroglycan.

o o

Normal vs. congenital dystrophy with low laminin. Many CMD patients have neuronal migration defects because of dystroglycan. Main defects are visual abnormalities. CM are primary muscle disorders. Most are mutations of contractile and structural proteins in the sarcoplasm and inclusions can be seen. Many myopathies and inclusion types. MC nemaline, centronuclear, central core and myofibrillar.

Nemaline (Rod shape with a-actinin component of Z bands), centronuclear (Small myofibers with central nuclei and central areas without contractile filaments).

o o

Kids look funny and have severe hypotonia. CM are rare. DDx of neonatal hypotonia includes Perinatal asphyxia Metabolic Disorders Congenital CNS abnormalities Spinal muscular atrophy (Werdnig-Hoffman disease).

What are ragged red fibers and what is their significance? o Shared myopathic findings among a variety of mitochondrial disorders. Peripheral rim represents aggregates of mitochondria.

Inflammatory Myopathies - Discuss the differences between polymyositis, dermatomyositis and inclusion body myositis (MC indication for biopsy). o Polymyositis Mainly muscle, little vessels.

Dermatomyositis

More inflammation and more vascular. Loss of fibers from inflammation. Inflammation is perivascular. Atrophy at the periphery along the CT border. Characteristic of dermatomyositis.

Dermatomyositis and polymyositis associated with scleroderma, mixed CT diseae and cancer. Patients may have cardiac involvement, HF, arthralgias. Raynauds, interstitial pneumonitis, renal involvement. Both can be treated with corticosteroids methotrexate and cyclosporine are used in severe cases.

Inclusion Body Myositis Atrophy and destruction Vascular lesions and necrosis.

Common in old people. Sporadic. Causes progressive, proximal and distal weakness with mild CK elevation. Weakness may be asymmetric. Affects individuals over 50. Refractory to corticosteroids and immunosupressives.

Describe the pathology of the various forms of rhabdomyosarcoma, & smooth muscle tumors. Rhabdomyosarcoma Chromosomal translocations are found in most cases. MC T(2:13) translocation fusing the PAX3 gene on chromosome 2 with FKHR gene in chromosome 13. PAX 3 functions upstream of genes that control skeletal muscle differentiation and tumor development. 5 major histologic categories.

Embryonal MC ST sarcoma of childhood and adolescence. MC in head and neck or GU tract sites with little to no skeletal muscle Range from highly differentiated neoplasms + rhabdomyoblasts with lots of eosinophilic cytoplasm to poorly differentiated. Many genetic abnormalities loss of genome material from 11p15, no gene amplification and hyperdiploid cellular DNA High cytologic variability several stages of muscle morphogenesis.

Alveolar You dont want this one. Bad! 31% cases. MC in adolescents. Mainly involves extremities, trunk and perianal/perirectal area. Unique translocation between FKHR gene on chromosome 13 and either the PAX3 gene on chromosome 2 (70%), t(2:13)(q37:14) or PAX 7 on chromosome 1 (30%), t(1:13)(q37, q14). Patients with PAX7 are younger and may live longer vs PAX3. Demonstrates gene amplification and DNA is tetrraploid. Tumors have the appearance of club-shaped tumor cells arranged in clumps and outlined by fibrous septa. In the center, the clusters are arranged loosely and appear in an alveolar pattern. Stain strong with eosinophilic stain.

Botyroid embryonal Grape like mass 6% cases of rhabdomyosarcoma. Seen in newborns. Mass in nose, not face. MC under mucosal surfaces, body orifices (vagina, bladder, nares)

Malignant cells in an abundant myxoid stroma.

Spindle cell embryonal 3% cases Mainly in paratesticular region. Rare in head and neck (vs. embryonal) Fascicular, spindled and leiomyomatous growth pattern. Notable rhabdomyoblastic differentiation and some present marked collagen deposition nested, storiform pattern.

Anaplastic Least common of all subtypes. MC in patients 30-50yoa. Rarely seen in children Large, lobate hyperchromatic nuclei and multipolar mitotic figures.

Prognosis o Alveolar has worse prognosis than embryonal possibly related to ploidy (hyperploid embrional vs. tetraploid alveolar). o Tx resection

Smooth Muscle Tumors. Leiomyoma o o o Most common Benign SM tumor Often arise in the uterus = MC neoplasm in women. Also seen in the erector pili muscles of the skin, nipples, scrotum and labia. Less frequently seen in deep ST. Those in the erector pili muscles are painful and multiple. o o o Occur mainly in adolescence and early adult life. Not larger than 1-2cm Composed of fascicles of spindle cells that tend to intersect each other at R angles. They have blunt ended, elongated nuclei and show minimal atypia and few mitotic figures. No hemorrhage or necrosis. o Solitary regions are easily cured. Numerous are more difficult.

Leiomyosarcomas o o o o 10-20%. MC in adults, more so in women vs. men. MC in skin and deep ST of the extremities and retroperitoneum. Painless firm masses. Retroperitoneal tumors may be >2cm (large) and bulky and cause abdominal sxs.

Composed of malignant spindle cells with cigar shaped nuclei in interweaving fascicles. High cellularity, nuclear pleomorphisms and at least 1 mitotic figure. Tumor giant cells present and necrosis as well as mitotic hot spots. Vascular invasion = poor prognosis. Stains + Masson trichrome myofibrils as red, longitudinal parallel lines. PAS + - Glycogen present. Reticulin Bundles of thin filaments surrounded by basal lamina.

Many variants.

Metabolic Myasthenia Lambert Eaton