Anatomic Pathology / ANTIH-CALDESMON FOR DISTINGUISHING SMOOTH MUSCLE AND MYOFIBROBLASTIC TUMORS
Is Antih-Caldesmon Useful for Distinguishing Smooth
Muscle and Myofibroblastic Tumors?
An Immunohistochemical Study
Katherine M. Ceballos, MD,1 Gunnlaugur P. Nielsen, MD,2 Martin K. Selig, BA,2 and
John X. OConnell, MB, FRCPC1
Key Words: h-Caldesmon; Immunohistochemistry; Myofibroblast; Smooth muscle
Abstract
Misinterpretation of positive staining of antibodies
to desmin, smooth muscle actin, and muscle actin as
representing smooth muscle differentiation in the
context of a spindle cell tumor is not uncommon.
Antih-caldesmon is a promising novel
immunohistochemical reagent for more specific smooth
muscle differentiation. We studied 72 tumors (11
leiomyosarcomas, 26 malignant fibrous histiocytomas
[MFHs], 11 fibromatoses, 11 cellular cutaneous fibrous
histiocytomas [CCFHs], 5 malignant peripheral nerve
sheath tumors, 4 synovial sarcomas, and 4 cases of
nodular fasciitis), the reactive myofibroblastic response
in 5 cases of acute cholecystitis, and the desmoplastic
response surrounding 5 invasive breast carcinomas.
Tissues were examined for expression of h-caldesmon,
desmin, smooth muscle actin, and muscle actin. Diffuse
staining for h-caldesmon was present only within the
leiomyosarcomas. Focal staining for h-caldesmon
involving less than 1% of lesional cells was present in 3
of 26 MFHs and 1 of 11 CCFHs. There was overlap in
staining for the other myoid markers in all of the
lesions that contained myofibroblasts. Antih-
caldesmon seems to be a reliable marker of smooth
muscle differentiation, and its inclusion in a panel of
myoid immunohistochemical reagents should allow
distinction of smooth muscle and myofibroblastic
tumors.
746 Am J Clin Pathol 2000;114:746-753
The spectrum of soft tissue tumors demonstrating myofi-
broblastic differentiation encompasses reactive proliferations
and benign and malignant neoplasms.1 Although the precise
identification of a myofibroblast requires ultrastructural
examination, in practice, most pathologists recognize myofi-
broblasts based on their light microscopic appearance and
appropriate immunohistochemical staining profile.1,2 Since
the latter exhibits extensive overlap with the immunohisto-
chemical staining profile of smooth muscle cells, this may
lead to imprecise classification of spindle cell tumors.3 In our
experience, the differentiation of myofibroblasts from smooth
muscle cells remains problematic in tumor pathology. The
standard panel of antibodies directed against myoid anti-
gens (desmin, muscle actin, smooth muscle actin) that is used
in the workup of spindle cell soft tissue tumors does not reli-
ably allow this distinction.3 Recent data suggest that a new
commercially available antibody directed against high-mo-
lecular-weight caldesmon (h-caldesmon) labels cells with
true smooth muscle cell morphologic features in a more
specific manner than previously available antibodies.4,5 The
purpose of the present study was to document the staining
reaction of anti-h-caldesmon with a variety of myofibrob-
lastic and true smooth muscle tumors. In addition, all of the
examined tumors also were studied using the aforementioned
panel of the standard conventional myoid markers.
Materials and Methods
Cases coded as musculoaponeurotic fibromatosis (11
cases), nodular fasciitis (4 cases), cellular cutaneous fibrous
histiocytoma (11 cases), malignant fibrous histiocytoma
(MFH; storiform-pleomorphic subtype, 26 cases), synovial
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sarcoma (4 cases), malignant peripheral nerve sheath tumor
(5 cases), and leiomyosarcoma (11 cases) were obtained
from the surgical pathology files of the Vancouver General
Hospital, Vancouver, British Columbia. Cases of infiltrating
breast carcinoma with surrounding desmoplastic stroma (5
cases) and acute cholecystitis with a reactive myofibroblastic
response (5 cases) were similarly obtained. The diagnostic
criteria used for each of the tumors and tumor-like lesions
are as follows:
1. Fibromatosis: a soft tissue tumor deep to the fascia
composed of intersecting fascicles of spindle cells embedded
in a richly collagenized background. The fascicles demon-
strate numerous thin-walled capillaries. Individual cells have
uniform elongate spindled nuclei with vesicular chromatin
and readily visible small nucleoli. Mitotic figures are infre-
quent Image 1.
2. Nodular fasciitis: a cellular soft tissue tumor
present within the subcutaneous tissue. The mass is focally
well circumscribed and associated with an organized
collagenous (fascial) layer. There is architectural variability
with cells arranged as sheets, fascicles, and storiform arrays
and, at least focally, a haphazard distribution within a capil-
lary-rich ground substance (tissue culturelike). Cytologi-
cally, the lesional cells exhibit plump oval to spindled nuclei,
vesicular chromatin, and, frequently, large nucleoli. The cells
have readily visible eosinophilic cytoplasm. Mitotic figures
are seen readily Image 2.
3. Cellular cutaneous fibrous histiocytoma: a dermal-
based cellular spindle cell tumor measuring less than 2.0 cm
with or without focal extension into the subcutaneous fat.
The tumor cells are arranged as sheets, storiform arrays, and
intersecting fascicles. At the center of the tumor, the dermal
collagen pattern is obliterated. The lateral edges of the mass
are poorly defined and contain hyalinized collagen bundles.
The lesional cells are plump spindle cells with eosinophilic
cytoplasm and elongate nuclei with stippled chromatin and
focally visible nucleoli. Occasional mitotic figures are
present Image 3.
4. MFH, storiform pleomorphic variant: a cellular
spindle and epithelioid cell neoplasm occurring within
subcutaneous or deep soft tissue. These tumors are character-
ized by marked architectural variability. Lesional cells may
be arranged as sheets, fascicles, and storiform arrays. Indi-
vidual cells demonstrate considerable variation in size,
shape, and nuclear morphologic features. Markedly irregular
hyperchromatic nuclei are found readily. Cytoplasm varies
from scant to abundant and is predominantly eosinophilic.
Distinct linear striations are not present. Mitotic figures,
including atypical forms, are readily present. Of importance,
in this group of neoplasms, no definite lineage differentiation
is present. Specifically, there is no light microscopic
evidence of adipose, endothelial, peripheral nerve, or myoid
American Society of Clinical Pathologists
Anatomic Pathology / ORIGINAL ARTICLE
differentiation. In practice, all of the tumors classified as
MFH were worked up using a full immunohistochemical
panel (not including h-caldesmon) at the time of original
diagnosis, and, in addition, ultrastructural examination was
performed in 16 of the tumors. This workup failed to show
any features of smooth muscle differentiation in any of these
tumors. This group of tumors was extremely variable in its
architecture, and tissue blocks demonstrating at least a focal
fascicular growth pattern were chosen for the immunohisto-
chemical staining in this study Image 4.
5. Leiomyosarcoma: a cutaneous, subcutaneous, or
deeply located soft tissue neoplasm composed of intersecting
fascicles of plump spindle cells with abundant eosinophilic
cytoplasm. The cells demonstrate considerable variation in
nuclear size, shape, and morphologic features; however, the
majority exhibit hyperchromatic nuclei. The neoplastic cells
contain abundant eosinophilic cytoplasm that shows focal
irregular intracytoplasmic vacuoles. Distinct linear fibrillarity
is present within the cytoplasm of many of the cells. Cell
membranes typically are seen readily. Mitotic figures are
present, including atypical forms. In general, the tumors
classified as leiomyosarcomas exhibited less architectural
variability than the MFHs. Ultrastructural examination,
which could be performed in 4 of 11 cases, confirmed
features of smooth muscle cells Image 5.
6. Synovial sarcoma: a monophasic or biphasic
spindle and/or epithelioid cell sarcoma. The lesional spindle
cells demonstrate relatively uniform nuclei and a scant
tapering cytoplasmic process. The lesional cells are arranged
as sheets and fascicles and commonly are associated with
dense eosinophilic collagen. Marked nuclear pleomorphism
is not a feature of these tumors. Biphasic neoplasms have, in
addition to the characteristics of synovial sarcomas, true
glands and tubules, often with eosinophilic luminal contents.
7. Malignant peripheral nerve sheath tumor: a vari-
ably cellular spindle cell sarcoma composed of sheets and
fascicles of spindle cells with hyperchromatic wavy nuclei.
Mitoses are found readily, and these tumors typically demon-
strate varying cellularity and nuclear pleomorphism. In prac-
tice, at the time of diagnosis these tumors demonstrated
origin from a peripheral nerve, occurred in patients with
neurofibromatosis, or both.
Reactive myofibroblastic proliferations representing the
supporting stroma in conventional infiltrating ductal carci-
noma of the breast and the subserosal spindle cell prolifera-
tion on the surface of acutely inflamed gallbladders also
were examined.
Immunohistochemical Methods
Immunohistochemical stains were performed with an
avidin-biotin-peroxidase complex and a Ventana ES auto-
mated immunostainer (Ventana Medical Systems, Tucson,
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Ceballos et al / ANTIH-CALDESMON FOR DISTINGUISHING SMOOTH MUSCLE AND MYOFIBROBLASTIC TUMORS
Image 1 Fascicles of cellular collagen-rich fibromatosis
(H&E, 200).
Image 3 The deep aspect of a cellular cutaneous fibrous
histiocytoma demonstrating the intense cellularity, mild
atypia and focal fascicular growth (H&E, 200).
AZ) using the antibodies listed in Table 1 and a 32-minute
incubation period. Sections stained with antih-caldesmon or
anti-desmin underwent heat-induced epitope retrieval before
staining. The deparaffinized slides were sealed in a container
containing citrate buffer and placed in a pressure cooker.
These slides were then microwaved on high and allowed to
boil for 4 minutes and to sit for 20 minutes. The slides were
cooled under running distilled water. Sections of leiomyoma
were used as positive controls, and sections of synovial
sarcoma were used as negative controls.
748 Am J Clin Pathol 2000;114:746-753
Image 2 Cellular focus of nodular fasciitis demonstrating
poorly formed storiform arrays (H&E, 200).
Image 4 High-grade malignant fibrous histiocytoma
demonstrating storiform growth and focal tumor giant cells
(H&E, 200).
Results
Positive staining was scored on a 0 to 3+ scale based on
the percentage of tumor cells stained in each lesion (0, no
staining; 1+, <25% of cells; 2+, 25%-75% of cells; and 3+,
>75% of cells). The staining results are summarized in
Table 2. Briefly, 10 of 11 leiomyosarcomas were labeled
diffusely with antibodies to h-caldesmon. In these cases,
more than 99% of the tumor cells typically were labeled
Image 6. In 1 case, the staining was focal, involving less
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 Anatomic Pathology / ORIGINAL ARTICLE

of the other myoid markers in 11 of 26 MFHs, 11 of 11 fibro-

matoses, 4 of 4 cases of nodular fasciitis, and 7 of 11 cellular
cutaneous fibrous histiocytomas. Although, in general, this
staining was focal (compared with the diffuse staining seen in
leiomyosarcoma), in many cases the staining for antismooth
muscle actin and muscle actin affected the majority of the cells
in a single region Image 9 and Image 10.
Staining for desmin occasionally exhibited this appear-
ance, particularly in cases of fasciitis and fibromatosis,
whereas in cellular cutaneous fibrous histiocytoma, it was
typically present in more dispersed cells Image 11. The
desmoplastic stroma in 5 of 5 infiltrating breast carcinomas
and myofibroblastic reaction in 5 of 5 cases of acute chole-
cystitis also exhibited focal or diffuse staining with 1 or more
myoid markers.

Image 5 Fascicular growth of a typical leiomyosarcoma

(H&E, 200). Discussion

Table 1 Myofibroblasts demonstrate morphologic features

Antibodies* intermediate between fibroblasts and smooth muscle cells.2
In addition to the overlap that exists at the level of light
Immunohistochemical
Stain Clone Dilution Pretreatment microscopy, myofibroblasts and smooth muscle cells also
demonstrate overlapping immunohistochemical staining
h-Caldesmon h-CD 1:400 Microwave
Desmin D33 1:200 Microwave
profiles using antibodies to actin, smooth muscle actin, and
Muscle actin HHF35 1:100 None desmin.1,3 The 2 cell types can be distinguished ultrastruc-
Alpha smooth turally2; however, in practical terms, the limited availability
muscle actin 1A4 1:200 None
of diagnostic electron microscopy facilities hinders the
* All from DAKO, Carpinteria, CA. usefulness of this technique in surgical pathology. Under
normal circumstances, myofibroblasts occur in granula-
than 25% of the tumor cells. This tumor (case 7) was a grade tion tissue and healing scars.2 Cells exhibiting myofibro-
3/3 sarcoma that had been irradiated before resection, and blastic morphology have been recognized as the principal
the tumor cells demonstrated marked nuclear degenerative cellular com-ponent of numerous soft tissue tumors,
changes suggestive of irradiation effect. In addition, the other including nodular fasciitis, mammary myofibroblastoma,
muscle markers (desmin, smooth muscle actin, and muscle dermatomyofibroma, intranodal myofibroblastoma, fibro-
actin) also stained the tumor cells in a more focal manner matoses, low-grade myofibroblastic sarcoma, and many
than in the remainder of the cases, suggesting that antigen others.1,6 In addition, tumors classified as so-called MFH
preservation in this sample may have been suboptimal. frequently demonstrate ultrastructural features of various
In 2 of the leiomyosarcomas, there was an abrupt transi- subtypes of fibroblasts, including myofibroblasts.7
tion between conventional leiomyosarcoma and undifferenti- In our experience, precise classification of spindle cell
ated MFH-like sarcoma. We classified these tumors as soft tissue tumors is frequently troublesome, and positive
dedifferentiated leiomyosarcomas and noted that the posi- immunohistochemical staining for muscle actin, smooth
tive staining for h-caldesmon was restricted to the regions of muscle actin, and/or desmin is interpreted mistakenly, not
morphologically typical leiomyosarcoma only Image 7. uncommonly, as representing evidence of smooth muscle
Antih-caldesmon failed to stain any cells in the cases of differentiation. Antih-caldesmon, by being a more specific
nodular fasciitis, fibromatosis, synovial sarcoma, or malignant identifier of smooth muscle differentiation, potentially would
peripheral nerve sheath tumor or in the desmoplastic stroma or be helpful in this regard by allowing appropriate classifica-
reactive myofibroblasts in the cases of infiltrating breast carci- tion of spindle cell tumors exhibiting myofibroblastic or
noma and acute cholecystitis, respectively. There was focal smooth muscle differentiation.
staining of less than 1% of the lesional cells in 3 of the MFHs Caldesmon is a cytoskeleton-associated protein present
Image 8 and 1 of the cellular cutaneous fibrous histiocy- in smooth and nonsmooth muscle cells.8-11 It functions by
tomas. As outlined in Table 2, there was staining for 1 or more binding calmodulin and Ca2+ and is involved in the regulation

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Table 2
Summary of Staining Results

AntiSmooth
Diagnosis Case No. Antih-Caldesmon Desmin Anti-Muscle Actin Muscle Actin

Leiomyosarcoma 1 3+ 3+ 3+ 3+
2 3+ 3+ 3+ 3+
3 3+ 3+ 3+ 3+
4 3+ 3+ 3+ 3+
5 3+ 3+ 3+ 3+
6 3+ 2+ 3+ 3+
7 1+ 2+ 1+ 2+
8 3+ 3+ 3+ 3+
9 3+ 3+ 3+ 3+
10* 3+ 3+ 3+ 3+
11* 3+ 3+ 3+ 3+
MFH 1 0 0 0 0
2 0 0 0 VF
3 0 0 0 0
4 0 0 0 0
5 VF 0 0 2+
6 0 0 0 0
7 VF 0 0 0
8 0 0 0 0
9 0 0 0 1+
10 0 1+ 0 0
11 0 0 0 0
12 0 0 0 0
13 0 0 0 0
14 0 0 0 1+
15 0 0 0 0
16 0 0 0 0
17 0 0 0 0
18 0 0 0 0
19 0 0 1+ 2+
20 0 0 0 0
21 0 1+ 1+ 1+
22 VF 1+ 0 1+
23 0 0 0 0
24 0 VF 1+ 1+
25 0 0 0 1+
26 0 1+ 0 1+
Synovial sarcoma 1 0 0 0 0
2 0 0 0 0
3 0 0 0 0
4 0 0 0 0
MPNST 1 0 0 VF 1+
2 0 0 VF 1+
3 0 0 0 0
4 0 0 0 0
5 0 0 0 0
Fibromatosis 1 0 1+ 0 1+
2 0 1+ 1+ 1+
3 0 1+ 1+ 2+
4 0 1+ 1+ 2+
5 0 1+ 1+ 1+
6 0 1+ 1+ 1+
7 0 0 0 1+
8 0 1+ 1+ 1+
9 0 0 1+ 1+
10 0 1+ 0 1+
11 0 0 1+ 2+
Nodular fasciitis 1 0 0 2+ 3+
2 0 0 0 3+
3 0 0 0 2+
4 0 0 1+ 3+
CCFH 1 0 0 0 1+
2 0 1+ 1+ 1+
3 0 0 0 0
4 0 0 0 0
5 0 1+ 0 1+
6 0 0 0 0
7 VF 0 0 1+
8 0 0 0 0
9 0 0 0 1+
10 0 1+ 0 0
11 0 0 0 1+
Desmoplastic stroma 1 0 0 1+ 3+
2 0 0 2+ 3+
3 0 0 0 2+
4 0 0 1+ 2+
5 0 0 1+ 3+
Myofibroblastic reaction 1 0 0 2+ 3+
2 0 0 1+ 1+
3 0 0 1+ 2+
4 0 0 1+ 2+
5 0 0 0 1+

CCFH, cellular cutaneous fibrous histiocytoma; MFH, malignant fibrous histiocytoma; MPNST, malignant peripheral nerve sheath tumor; VF, very focal staining involving <1%
of the tumor cells; 0, no staining; 1+, <25% of cells; 2+, 25%-75% of cells; 3+, >75% of cells.
* Dedifferentiated leiomyosarcoma; positive staining in conventional areas only.
Desmoplastic stroma surrounding invasive breast carcinoma.
Myofibroblastic reaction occurring on the surface of the gallbladder in acute cholecystitis.

750 Am J Clin Pathol 2000;114:746-753 American Society of Clinical Pathologists

 Anatomic Pathology / ORIGINAL ARTICLE

of cellular contraction.8-11 High- and low-molecular-weight
forms of the protein occur.8,9 The high-molecular-weight
form is thought to be restricted to smooth muscle and
myoepithelial cells.5 There have been few studies of the
expression of h-caldesmon in soft tissue tumors. Watanabe et
al4 demonstrated that h-caldesmon expression was limited to
soft tissue neoplasms demonstrating smooth muscle differen-
tiation. Leiomyomas, angioleiomyomas, leiomyosarcomas,
and glomus tumors were consistently diffusely and strongly
positive for antih-caldesmon, whereas MFHs, inflammatory
Image 6 Diffuse cytoplasmic staining for h-caldesmon in
virtually every cell of this leiomyosarcoma (200).
myofibroblastic tumors, desmoid tumors, and a variety of
myoepithelial-type neoplasms were consistently negative.4
These investigators noted extensive staining in all tumors
tested for antibodies directed against actin (HHF35) and
smooth muscle actin,4 as we did. Two of 8 gastrointestinal
stromal tumors tested also exhibited positive staining for h-
caldesmon. Watanabe et al4 concluded . . . that h-caldesmon
can be used as a specific marker of smooth muscle cells and
tumors originating from smooth muscle cells.
Miettinen et al5 reported very similar results, demon-
strating h-caldesmon staining in 96% of 90 examined
visceral and soft tissue tumors demonstrating smooth muscle
differentiation. Four of 31 retroperitoneal leiomyosarcomas
were the only smooth muscle tumors that failed to stain posi-
tively.5 On the other hand, 6 cases of nodular fasciitis and 10
desmoid tumors failed to demonstrate positive staining.5
Miettinen et al5 recorded focal staining involving less than
10% of tumor cells in 11 of 15 tumors classified as MFH and
in the dedifferentiated regions of dedifferentiated liposar-
coma in 6 of 10 tumors. In contrast, these investigators noted
that positive staining for h-caldesmon was restricted to the
well-differentiated component of several examined uterine
leiomyosarcomas.5 Overall, these results are rather similar to
our own. As both of these groups of investigators have
described, antih-caldesmon typically stains the vast
majority of cells in smooth muscle tumors.4,5
We also noted focal positive staining in fewer than 1%
of tumor cells in 3 of 26 MFHs and in 1 of 11 cellular cuta-
neous fibrous histiocytomas in our study group. Although we
found diffuse positive staining in 10 of 11 tumors classified

A B

Image 7 A, Section of one of the tumors we classified as a dedifferentiated leiomyosarcoma. The well-differentiated
leiomyosarcoma is present in the lower half of the image. The upper half consists of an undifferentiated malignant fibrous
histiocytomalike pleomorphic sarcoma (H&E, 100). B, h-Caldesmon staining of the region of the tumor shown in Image 7A.
Note the staining is confined to the well-differentiated component of the tumor (100).

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Ceballos et al / ANTIH-CALDESMON FOR DISTINGUISHING SMOOTH MUSCLE AND MYOFIBROBLASTIC TUMORS
Image 8 Rare h-caldesmonstained cells in one of the
tumors classified as malignant fibrous histiocytoma. This
was the field with the greatest number of positively stained
cells. Most cells in this tumor were not stained by antih-
caldesmon (200).
Image 10 Fibromatosis with strong staining (smooth
muscle actin, 200).
as conventional leiomyosarcoma, in 2 of the tumors in our
series, there was an abrupt transition between conventional
leiomyosarcoma and undifferentiated MFH-like sarcoma
(tumors that we classified as dedifferentiated leiomyosar-
comas). In these tumors, positive staining was restricted to
the morphologically typical leiomyosarcoma.
It has become increasingly clear that MFH, despite its
name, typically lacks definite histiocytic differentiation and,
752 Am J Clin Pathol 2000;114:746-753
Image 9 Nodular fasciitis demonstrating diffuse intense
staining (smooth muscle actin, 200).
Image 11 Cellular cutaneous fibrous histiocytoma showing
intense positive staining in a proportion of the tumor cells
(desmin, 200).
in practical terms, MFH is a diagnosis of exclusion.12,13 To
this end, the more histogenetically apt designations of
undifferentiated spindle cell sarcoma or sarcoma not
otherwise specified may be more appropriate for these
tumors. The percentage of high-grade sarcomas classified as
MFH seems to be inversely proportional to the effort with
which alternative lines of differentiation are sought. Our
experience with high-grade soft tissue sarcomas of adult-
American Society of Clinical Pathologists

hood is that a sizable number fail to show definite lineage
differentiation. In fact, this group represents the most
frequent high-grade sarcoma seen in our practice, accounting
for the large representation in this study. We readily
acknowledge that other pathologists may have classified
some of the MFHs in our study group as other types of high-
grade sarcoma; however, the cases that we have used fulfill
the diagnostic criteria outlined in the Methods section.
Nevertheless, based on the results of our staining and the
findings of Miettinen et al,5 it could be argued that indeed a
proportion of so-called MFHs may best be classified as
poorly differentiated leiomyosarcomas or, at least as Miet-
tinen et al5 propose, that the staining suggests . . . their
smooth muscle differentiation.
Antih-caldesmon may indeed help to further elucidate
the nature of some of the tumors currently classified as MFH;
however, we believe that the real usefulness of this antibody in
diagnostic surgical pathology relates to its ability to distin-
guish myofibroblasts from smooth muscle cells in settings
other than obvious high-grade soft tissue sarcomas. In this
regard, antih-caldesmon provides particular help in the
distinction of cellular cutaneous fibrous histiocytoma, fibro-
matosis, and nodular fasciitis from low-grade leiomyosar-
coma, a not uncommon differential diagnostic challenge. One
of the 11 tumors that we classified as a cellular cutaneous
fibrous histiocytoma showed rare positive tumor cells,
suggesting that scattered cells within these lesions may exhibit
a more functionally complete smooth muscle phenotype
(similar to a situation with poorly differentiated sarcomas such
as MFH). The focal presence of an individual positively
stained cell within myofibroblastic lesions should not be
completely unexpected in the setting of a neoplasm in which
cells may show a range of phenotypic differentiation. We
believe that immunohistochemical staining with antih-
caldesmon considerably aids in the distinction of smooth
muscle cell neoplasms from myofibroblastic tumors and that it
has a role as part of an immunohistochemical panel used in the
examination of selected soft tissue tumors.
From the Departments of Pathology, 1Vancouver General
Hospital, Vancouver, British Columbia, and 2Massachusetts
General Hospital, Boston, MA.
Address reprint requests to Dr OConnell: Dept of Pathology,
Vancouver General Hospital, 855 W 12th Ave, Vancouver, BC,
Canada V5Z IM9.
American Society of Clinical Pathologists
Anatomic Pathology / ORIGINAL ARTICLE
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