ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 50 No. 1, 2009

1. From conventional pathologic diagnosis to the molecular classification of breast carcinoma: are we ready for the change?

M. Raica, I. Jung, Anca Maria Cîmpean, C. Suciu, Anca Maria Mureşan

Breast cancer is the most frequent malignant tumor in women and the diagnosis, prognosis and therapeutic strategy are based on the pathologic report. In last years, it was shown that conventional pathologic diagnosis brings few data about prognosis and tells nothing about the response of the tumor to specific therapy. In an effort to improve the molecular characterization of breast cancer, gene profile analysis was performed in a large number of cases. Based on this analysis, there were characterized five molecularly different subclasses: basal-like, luminal type A and B, HER-2, and unclassified. It was shown that prognosis and response to adjuvant therapy is significantly different in these five subtypes. Immunohistochemistry was demonstrated to be a good and acceptable surrogate of the gene analysis. A panel of antibody that includes estrogen receptors (ER), progesterone receptors (PR), Her2 protein, cytokeratin 5 (CK5), epidermal growth factor receptor (EGFR), p53 mutation, and Bcl-2 expression, can discriminate between these five molecular subclasses. In the present review there are presented the main characteristics of the molecular subclasses, the relationships with the conventional pathologic classification, critical problems of the molecular classification and their impact on prognosis and therapy.

Corresponding author: Marius Raica, MD, PhD, e-mail: raica@umft.ro

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2. Properties and medical applications of shape memory alloys

Daniela Tarniță, D. N. Tarniță, N. Bîzdoacă, I. Mîndrilă, Mirela Vasilescu

One of the most known intelligent material is nitinol, which offers many functional advantages over conventional implantable alloys. Applications of SMA to the biomedical field have been successful because of their functional qualities, enhancing both the possibility and the execution of less invasive surgeries. The biocompatibility of these alloys is one of their most important features. Different applications exploit the shape memory effect (one-way or two-way) and the super elasticity, so that they can be employed in orthopedic and cardiovascular applications, as well as in the manufacture of new surgical tools. Therefore, one can say that smart materials, especially SMA, are becoming noticeable in the biomedical field. Super elastic NiTi has become a material of strategic importance as it allows to overcome a wide range of technical and design issues relating to the miniaturization of medical devices and the increasing trend for less invasive and therefore less traumatic procedures. This paper will consider just why the main properties of shape memory alloys hold so many opportunities for medical devices and will review a selection of current applications.

Corresponding author: Daniela Tarniță, Eng, PhD, e-mail: dtarnita@yahoo.com

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3. Effect of alpha lipoic acid on oxidative stress and vascular wall of diabetic rats

Siti Balkis Budin, Faizah Othman, S. R. Louis, M. Abu Bakar, M. Radzi, K. Osman, S. Das, J. Mohamed

Premises and objectives: Antioxidant plays an important role in preventing the progression of diabetes mellitus (DM) complications. The aim of the present study was to investigate the effect of alpha lipoic acid (ALA) supplementation on plasma lipid, oxidative stress and vascular changes in diabetic rats. Material and methods: Diabetes was induced by a single intravenous injection of streptozotocin (STZ) (50 mg/kg). The diabetic rats were divided into two groups: (i) supplemented group with ALA (100 mg/kg/day) and (ii) non-supplemented group without ALA. Non-diabetic rats (NDM) formed the control group, which received saline injection. Results: Following eight weeks of supplementation, fasting blood glucose (FBG) and glycosylated hemoglobin (HBA1c) in ALA-supplemented rats was found to be significantly lower than the non-supplemented group. ALA-supplementation also improved dyslipidemia that occurred in diabetic rats. ALA-supplementation also significantly increased plasma superoxide dismutase (SOD) activity and vitamin C level as compared to the No Suppl group. The increase in plasma and aorta malondealdehyde + 4-hydroxynonenal (MDA + 4-HNE) levels were also inhibited and the levels of oxidative DNA damage of peripheral lymphocytes were significantly reduced. Electron microscopic examination of thoracic aorta revealed that normal tissue organization was disrupted in STZ-diabetic rats with ALA-supplementation reducing the changes in the vascular morphology. Conclusions: It is concluded that ALA has the potential in preventing the alteration of vascular morphology in diabetic rats probably through the improvement of glycemic status and dyslipidemia as well as its antioxidant activities.

Corresponding author: Siti Balkis Budin, PhD, e-mail: amira@medic.ukm.my

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4. Cathepsin-D expression in breast lesion: an immunohistochemical study

Iulia Brujan, Cl. Mărgăritescu, Cristiana Simionescu, D. Pirici, A. Fronie, Camelia Foarfă, A. Stepan, Maria Vrabete

Cathepsin-D (CathD) is an aspartyl lysosomal protease expressed in all tissues that might play a role in antigen processing, cell proliferation and tissue renewal, and activation of different pro hormones. The aim of our study was to compare the expression of CathD in most common breast tumors and tumor-like breast lesions. The study includes 21 patients with histologically verified breast lesions (adenosis, ductal hyperplasia, fibroadenomas, and different types of invasive carcinoma). We investigated the cathepsin-D expression in these breast lesions using immunohistochemistry (IH; paraffin-embedded tissues). Cathepsin-D staining within each lesion was assessed by estimating the area of the objects and the medium pixel intensity per object, as the integrated optical density (IOD). The immunostaining was more obvious in breast invasive carcinomas and macrophages. The reaction in tumor tissue was heterogeneous with little variation of staining intensity in positive tumor cells. Adenosis had the maximum area/signal intensity from all studied breast benign lesions (p<0.001, Student t-test). The general tendency (all benign lesions, lobular carcinomas and G3 ductal invasive carcinoma) was a more prominent representation of the cellular compartment. In the G3 ductal invasive carcinoma-type, the group of patients with metastases had a stronger expression in the cellular compartment. These results suggest that CathD expression was strongest in malignant than in benign breast disease, the positivity being present in both epithelial neoplastic and stromal cells. We also conclude that our procedure in IOD measurement is prone to less subjective-related biases, and thus more accurate and constant than other methods employed by other authors.

Corresponding author: Claudiu Mărgăritescu, MD, PhD, e-mail: c_margaritescu2000@yahoo.com

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5. Gastric cancer: the correlation between the clinicopathological factors and patients survival (I)

Daniela Lazăr, Sorina Tăban, Alis Dema, Mărioara Cornianu, A. Goldiş, Iulia Rațiu, I. Sporea

Introduction: The prognosis of the gastric cancer is generally reserved. The purpose of this study consists in the identification of the clinicopathological parameters that influence the prognosis of the patients that underwent surgery for gastric cancer. Material and Methods: Out of a total amount of 265 patients (186 males and 79 females) clinically and histopathologically diagnosed with gastric cancer, 61 patients operated for this disease have been selected from the Surgical Departments of the Emergency County Hospital in Timisoara. A prospective study was conducted on this group, regarding the gastric cancer's evolution and aggressiveness, for a period of 5 years. The survival time was calculated starting with the month when the surgery took place, and up to the month of death or that of the survival confirmation, and the survival rate was represented by the percentage of survivals at the end of the tracked period (in years and months). Results: The study group was formed of 61 patients (43 males and 18 females) of ages between 30 and 80 years (mean age = 59.34 years). Gastric cancer was encountered more frequently in males (70.5%) than in females (29.5%) (p<0.001 ES). The amount of gastric cancer cases grows with age, the highest percents being observed in patients from the 51-70 years age group. However, the incidence is significantly lower after the age of 71 - 8.2% (p<0.001 ES). Antral localization of the gastric cancer predominates in both males and females, for all the age groups (50.8%). The average 5 years survival rate, for the whole group has been of 16.4%. We remark the extremely low survival rate for the older patients. In our study, we have identified five early gastric carcinomas (8.2%), classified as being type I protrusive tumors of intestinal type and 56 advanced gastric carcinomas, 16 cases in females (28.6%) and 40 cases in males (71.4%). The average survival for the patients with advanced gastric cancers was of 13.9 months, significantly lower than the average survival value of the patients with early gastric cancers (57.2 months). According to Borrmann's classification, we have identified five type I carcinomas (8.9%), 20 type II carcinomas (35.7%), 22 type III carcinomas (39.3%), and nine type IV carcinomas (16.1%). We did not notice any significant differences between the survival values of the patients with tumors of types I, II and III (p>0.05 NS), but the patients with diffuse infiltrative gastric cancers had an average survival of only 4.9 months after the surgery. Conclusions: The prognosis for gastric cancer is reserved, the 5 years average survival rate is of 16.4%. We have noticed a significantly decrease of survival rate with age (p = 0.024688 S). The 5 years survival is of 10.7% for patients with advanced cancers, significantly lower than the 5 years survival of 80% for patients with early gastric cancers (p<0.001 ES).The ulcerative-infiltrative type of cancer is predominant (39.3%). The patients with diffuse infiltrative forms of gastric cancers survived for an average period of only 4.9 months after surgical intervention.

Corresponding author: Daniela Lazăr, MD, PhD, e-mail: lazar_daniela@yahoo.com

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6. The evaluation of the sentinel lymph nodes status in breast carcinoma using microscopic, immunohistochemical and cytomorphometric methods in order to establish new stadializations and therapeutic schemes

Simona Stolnicu, M. Fl. Coros, Daniela Maria Podeanu, E. Carata, T. Mezei, Simona Muscă, C. Podoleanu, Doinița Rădulescu

The state of axillary lymph nodes represents the most important prognostic parameter in patients with breast carcinoma. The biopsy and examination of sentinel lymph nodes, the former one containing metastases originating in mammary carcinoma, allows a better stadialization of the tumor but also the avoiding of the extirpation of the axilla, associated with a series of complications and high costs of hospitalization. In establishing the tumoral prognosis, not only the diameter but also the localization of the metastasis in the lymph nodes is utterly important. The evaluation of the metastases was carried out through the serial examination of the sentinel lymph node correlated to immunohistochemical examinations with AE1/AE3. Of the 570 patients with breast carcinoma evaluated in this research, 250 had macrometastases, 93 micrometastases, only 23 had isolated tumor cells, and in the case of 204 no metastases were found. The technique of computerized cytomorphometry allowed a better evaluation of the diameter and localization of the metastases in the lymph nodes than the examination through optical microscope. The tumoral prognosis in the case of patients with macrometastases is poorer than that of patients with micrometastases. The patients in whom only the presence of isolated tumoral cells was demonstrated have a similar prognosis with those who do not have metastases. As far as the localization of micrometastases in the sentinel lymph nodes is concerned, those with a subcapsular localization are associated with a poorer prognosis than those with an intraparenchymatous localization. As well as this, the subcapsular localization of micrometastases was also associated with the diameter of the primary tumor extending between 2-5 centimeters, a high microscopic grade, the presence of lymph vascular emboli and microscopic type of the primary tumor associated with poor prognosis. On the other hand, the presence of isolated tumoral cells was associated with tumors of a small diameter lacking the presence of lymph vascular emboli and with a low microscopic grade. All these data are essential in establishing the therapeutic management of the patients with breast carcinoma; consequently, we recommend their inclusion in future stadializations of this lesion and the evaluation of tumoral prognosis.

Corresponding author: Simona Stolnicu, MD, PhD, e-mail: stolnicu@gmx.net

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7. Experimental study on the effect of bile, and bile and hydrochloric acid mixture on the esophageal mucosa

Georgeta Simona Manea, Cătălina Lupuşoru, Irina-Draga Căruntu

Introduction: The investigation of duodena gastro esophageal reflux (DGER) implies both clinical and experimental studies. Within the context of the literature, our study aimed to produce esophageal lesions by the development of an experimental model reproducing the characteristics of DGER and to analyze their microscopic pattern. Material and Methods: The material consisted in three groups of white Wistar rats. Group I (control group) included physiologic saline gavaged rats. Group II received by the esophageal probe bovine bile pH 7, and group III 0.5% bovine bile at pH 4, to which we added hydrochloric acid 0.1 N. The rats were sacrificed in the 21st day of the experiment. The esophagus was sectioned obliquely and longitudinally, maintaining the lumen and marking the upper and lower extremities. The esophageal fragments were routinely processed for light microscopy pathology exam, in HE staining. Results: The pathologic aspects suggested that the effect of bile and bile and hydrochloric acid mixture on the esophageal epithelium interferes with the normal keratinization process, with consequent onset of hyperkeratinization. Moreover, epithelial atrophy was present in the group II on restricted areas and in the group III on extended territories. Discussion: The alterations in the keratinization process suggest the possibility of initiation in time of carcinogenic mechanism. The atrophic transformations plead for an evolution towards erosion and ulceration. The study takes into consideration the differences between human and experimental animal esophageal epithelium. Conclusions: Thus, there emerge new perspectives to extrapolate the experimental results into the human biologic context, the morphologic pattern proving the irritant effect of DGER in vivo.

Corresponding author: Georgeta Simona Manea, MD, PhD candidate, e-mail: simonamaneamd@yahoo.com

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8. Clinical and histopathological correlations of the modifications of fetal membranes in amniochorial infection

Anca Pătraşcu, Sabina Berceanu, Carmen Florina Popescu, V. Gheorman, C. Berceanu

The paper aims at analyzing the histopathological modifications induced by the amniotic infection on present fetal membranes and in the absence of clinical signs of chorioamnionitis. Such an evaluation is important in the context of postpartum fetomaternal complications. The objective was to determine the relation between the microbial invasion in the amniotic cavity and the severity of inflammatory lesions of the placenta, of the membranes and the umbilical chord.

Corresponding author: Anca Pătraşcu, MD, PhD, e-mail: patrascuanca@yahoo.com

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9. Isolation and characterization of mesenchymal stem cells from the amniotic membrane

Carmen Mihaela Mihu, D. Rus Ciucă, Olga Sorită, S. Şuşman, D. Mihu

The aim of the study was the isolation and the genotypic and phenotypic characterization of mesenchymal stem cells from the amniotic membrane. The placentas included in the study were derived from pregnancies with a normal evolution. Along with the placentas, umbilical cord blood and maternal peripheral blood samples were taken. The isolation and the culture of cells from the amniotic membrane was followed by the determination of the markers of these cells. The cells expressed markers characteristic of stem cells. Immunofluorescence and evaluation of the gene expression evidenced the pluripotential properties of these cells. HLA expression provides information that might help explain the immunological mechanisms of tolerance between the maternal organism and fetal structures.

Corresponding author: Carmen Mihaela Mihu, MD, PhD, e-mail: carmenmihu2004@yahoo.com

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10. Hypothesis of microfractures by buckling theory of bone's trabeculas from vertebral bodies affected by osteoporosis

Nina Ionovici, M. Negru, D. Grecu, Mirela Vasilescu, L. Mogoantă, Adriana Bold, Rodica Trăistaru

Osteoporosis has become in recent years a public health problem considered a true 'silent epidemic', by increasing the number of osteoporosis fractures in the world as a result of increased number of persons 3rd group of age by increasing life expectancy and reducing physical effort and the emergence of sedentary occupations, increasing incidence of obesity, diabetes, liver disease and kidney by applying widely corticosteroid therapy. Starting from the macroscopic and microscopic aspects of the bone spongy tissue affected by osteoporosis, from vertebral bodies, we try to explain the modality of damaging the bone micro-structure by buckling phenomenon, knowing that the bone tissue has at trabecular level, an elasticity degree and supports high levels of mechanical forces.

Corresponding author: Nina Ionovici, MD, PhD, e-mail: mogoanta@umfcv.ro

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11. Mast cells and dendritic cells in basal cell carcinoma

Albertine Leon, Zenaida Ceauşu, M. Ceauşu, Carmen Ardeleanu, Rodica Mehedinți

Basal cell carcinoma (BCC) is a very frequent skin malignancy, with slow evolution and rare metastases. Host tissues react to tumor invasion through complex inflammatory response, comprising varied inflammatory cells. We assessed the expression of mast cells and dendritic cells in 37 archived formalin-fixed paraffin-embedded tissue samples of BCC from the oral and maxillofacial region by means of immunohistochemical (IHC) method, using the SABC (Streptavidin-Biotin Complex) indirect tristadial technique for CD117 and S100 markers. Undetermined cases were eliminated. Mast cells were found in great number at the periphery and in between the tumor islands, the positivity to CD117 being high in three cases, moderate in 11 cases and low in 16 cases. Dendritic cells were also found within the tumor stroma, but they penetrated deep inside the tumor nests. The positivity to S100 was high in one of the 20 conclusive BCC cases, moderate in seven cases and low in nine cases. Three cases were negative to S100. The characteristic location of dendritic cells prove their role as antigen-receptor cells while mast cells might play dual roles in tumor biology.

Corresponding author: Albertine Leon, DMD, e-mail: dr_aleon@yahoo.com

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12. Evaluation of dental and maxillary development in patients with cleft lip alveolus

N. Galie, Magdalena Enache, L. Podoleanu, D. David, Elena Podoleanu, T. Spînu, Mădălina Olteanu

Our purpose was to determine in 20 unilateral cleft lip and alveolus subjects characteristics of the maxillary permanent teeth and maxillary arch development. Clinical and radiographic examinations have been carried out to identify congenitally missing teeth and sagittal skeletal patterns. Study cast assessment was undertaken to evaluate mesiodistal widths of individual teeth, intercanine and intermolar distances for the maxillary arch, as well as dental relationships. We observed that the congenital absence of the upper incisors was higher on the cleft side than on the non-cleft side. There was a statistically significant difference between the mesiodistal widths of cleft-side permanent upper lateral incisors, and their antimeres (p<0.05). Most of the patients presented a class II dental relationship on the affected side comparing to class I/class III Angle on the unaffected side. We concluded that patients with isolated cleft lip and alveolus present perturbations in dental and maxillary arch development, a more severe disruption being recorded on the cleft side.

Corresponding author: Nicolae Galie, MD, PhD, e-mail: nicolae_galie@yahoo.com

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13. An anatomical study of the thyroid arteries anastomoses

Adelina Maria Jianu, A. Motoc, Andreea Luminița Mihai, M. C. Rusu

Collateral circles in neck own a particular importance in compensating the symptoms due to the unilateral occlusion of the common carotid artery. In addition, surgical procedures at the level of the thyroid gland and larynx raise the problem of a good knowledge of the arterial morphology at those levels. The present study was designed to investigate the possible morphologies of the thyroid arteries anastomoses. For the present study, 20 human adult specimens were dissected, 15 in cadavers and other five on laryngeal specimens drawn at autopsies. Dissections evidenced bilateral and unilateral anastomoses of the thyroid arteries classified as extra laryngeal and intra laryngeal, the former constantly being represented by the supra isthmic arcade made by the superior thyroid arteries and the retrolobar anastomoses of the superior and inferior thyroid arteries. Constant intra laryngeal anastomoses were those of the superior laryngeal artery with the inferior laryngeal artery and, respectively, with the cricothyroid artery. The analogy with the cardiac collateral circulation, the thyroid arteries anastomoses may be classified as intrathyroid and interthyroid arterial anastomoses. We also present in this paper a rare variant that we did not find described in the references we investigated, represented by the paramedian perilaryngeal anastomose of the suprahyoid branch emerged from the lingual artery and the cricothyroid artery sent by the superior thyroid artery. The thyroid arteries supply the collateral circles in neck; the clinicians must be aware of their possible functional value and the surgeons must take into account these arterial morphologies while acting on the neck viscera.

Corresponding author: Adelina Maria Jianu, MD, PhD, e-mail: adelina.jianu@umft.ro

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14. Simultaneous immunophenotypical assessment of troponin and extracellular matrix molecules in myocardium of patients with sudden cardiac death

M. Ceauşu, C. Curcă, D. Dermengiu, Carmen Ardeleanu

In patients with sudden unexpected cardiac death, there is a relationship between the interstitial fibrosis of the myocardium and matrix molecules with a role in global remodeling of the cardiac stroma. Tissue samples of left ventricular myocardium from 17 middle-aged patients with sudden cardiac death, following acute or chronic ischemic cardio(myo)pathies, were analyzed using standard HE stain and the indirect tristadial ABC peroxidase immunohistochemical method for a panel of four antibodies involved in the dynamic remodeling of extracellular matrix: matrix metalloproteinase 9 (MMP9), tenascin X (Tn-X), TGF-b, CD54 (ICAM-1), together with simultaneously assessment of troponin in myocardic fibers. The most sensitive reaction was noticed for ICAM-1 in 71% of cases, followed by MMP9 in 59% of cases and TGF-b in 47% of cases (with great specificity for capillary vessels), in the extracellular matrix of the residual cardiomyocytes. A direct correlation, statistically significant was recorded between troponin and MMP9 (r = 0.65, p = 0.01), troponin and ICAM-1 (r = 0.31, p = 0.02), respectively ICAM-1 and tenascin (r = 0.72, p = 0.01). The extensive expression of ICAM-1 in the extracellular matrix from the perilesional area probably plays a role in the stimulation of new developing adhesion substrates between residual cells and adjacent stroma, while the over expression of troponin in the residual cardiomyocytes is accompanied by a high expression of MMP9 in the myocardic interstitium, with heterogeneous remodeling of the ventricular stroma. The simultaneous IHC expression of tenascin and ICAM-1 suggests a colocalization required for the nerve sprouting in the residual myocardium and for developing new focal cell-matrix adhesion contacts.

Corresponding author: Mihai Ceauşu, MD, PhD, e-mail: ceausu_mihai@yahoo.com

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15. Duplication of falx cerebelli, occipital sinus, and internal occipital crest

Sujatha D'Costa, A. Krishnamurthy, S. R. Nayak, Sampath Madhyasta, Latha V. Prabhu, Jiji P. J, Anu V. Ranade, Mangala M. Pai, Rajanigandha Vadgaonkar, C. Ganesh Kumar, Rajalakshmi Rai

The incidence of variations of falx cerebelli was studied in 52 adult cadavers of south Indian origin, at Kasturba Medical College Mangalore, after removal of calvaria. In eight (15.4%) cases, we observed duplicated falx cerebelli along with duplicated occipital sinus and internal occipital crest. The length and the distance between each of the falces were measured. The mean length of the right falces cerebelli was 38 mm and the left was 41 mm. The mean distance between these two falces was 20 mm. No marginal sinus was detected. Each of the falces cerebelli had distinct base and apex and possessed a distinct occipital venous sinus on each attached border. These sinuses were noted to drain into the left and right transverse sinus respectively. After detaching the dura mater from inner bony surface of the occipital bone, it was noted that there were two distinct internal occipital crests arising and diverging inferiorly near the posterolateral borders of foramen magnum. The brain from these cadavers appeared grossly normal with no defect of the vermis. Neurosurgeons and neuroradiologists should be aware of such variations, as these could be potential sources of hemorrhage during suboccipital approaches or may lead to erroneous interpretations of imaging of the posterior cranial fossa.

Corresponding author: Sujatha D'Costa, MSc, e-mail: sujathasn@gmail.com

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16. A cadaveric study in the Indian population of the brachialis muscle innervation by the radial nerve

Prakash, Jyoti Kumari, N. Singh, G. Rahul Deep, T. Akhtar, N. S. Sridevi

Radial nerve innervation to the brachialis mucle has been studied previously by different authors in Caucasian, Chinese, and Thai population. Present study was aimed to describe the radial nerve and musculocutaneous nerve contribution to the brachialis muscle and to elucidate racial differences between Indian and other populations. Hundred-forty superior extremities of 70 embalmed cadavers including 29 female and 41 male cadavers were dissected to study the innervation of brachialis muscle by musculocutaneous nerve and branch from the radial nerve. All the specimens were studied for site of penetration, level of distribution and nature of course and pathway of the branch of the radial nerve to the brachialis muscle. The musculocutaneous nerve innervated the brachialis muscle in 100% specimens, whereas the radial nerve in 72.14% specimens. The radial nerve branch to brachialis pierced the muscle in the lower one third of the humerus in 65.71% specimens; on the other hand in the middle one third in 34.29% specimens. The radial nerve branch to brachialis in 50.71% specimens had relatively straighter course before penetration into the muscle, whereas in 49.29% specimens the nerve had relatively curved course and pathway. Aforementioned results regarding brachialis innervation by radial nerve in Indian population is different from studies reported in other populations. These anatomical facts are important for humeral surgery including both the anterior and posterior approaches especially for orthopedic interventions on the Indian population.

Corresponding author: Prakash, MD, e-mail: prakashrinku@rediffmail.com

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17. Solitary angiokeratoma of the tonsillar pillar of the oral cavity

A. Fernandez-Flores, J. Sanroman

Solitary angiokeratoma has rarely been described in oral mucosa, mainly in the tongue, where the main concern is either aesthetical or due to bleeding problems. We present a case of solitary angiokeratoma of the tonsillar pillar in a 68-year-old man. Histologically, the morphology was typical of angiokeratoma. It showed an immunohistochemical pattern in consonance with a blood vessel origin, with expression of CD31, CD34, and von Willebrand factor. The lesion did not express D2-40. No other malformation or metabolic disorder was found in the patient. The lesion was surgically removed and due to the disproportionate post-surgery bleeding, the patient was studied by the Hematology Service, and she was diagnosed as an inhibitor of Factor VIII carrier.

Corresponding author: Angel Fernandez-Flores, MD, PhD, e-mail: gpyauflowerlion@terra.es

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18. Tuberous sclerosis complex: report of two intrafamilial cases, both in mother and daughter

Daniela Dumitrescu, E. F. Georgescu, Mihaela Niculescu, Cristiana Iulia Dumitrescu, S. S. Mogoantă, Iuliana Georgescu

Tuberous sclerosis complex (TSC) is a multisystem syndrome characterized by neurological symptoms and tumors in multiple organs including kidney, brain, skin, eyes, heart and lung. Kidney and brain are the two most frequently affected organs in TSC. TSC is an autosomal disorder with extensive clinical variability. We described TSC in a family at a mother and her daughter. We emphasized the importance of Computed Tomography in the discovery of some asymptomatic organic involvement as bilateral renal angiolipoma in the mother.

Corresponding author: Daniela Dumitrescu, MD, PhD, e-mail: daniela.dumitrescu@gmail.com

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19. Unusual renal carcinoma with a double component: case report and review of the literature

Alina Sovrea, Renata Vasiu, M. Raica, Anne-Marie Chindriş

The authors report a rare case of a 60-year-old man who had in his left kidney a tumor with two distinct components: a tubulo-papillary pattern and an extensive high-grade squamous cell carcinoma. The literature concerning this subject will be also reviewed.

Corresponding author: Alina Sovrea, MD, PhD, e-mail: a_sovrea@yahoo.com

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20. Multiple arterial, neural and muscular variations in upper limb of a single cadaver

Venkata Ramana Vollala, Somayaji Nagabhooshana, Seetharama Manjunatha Bhat, Bhagath Kumar Potu, V. Rodrigues, N. Pamidi

During routine dissection classes to undergraduate medical students, we have observed some important anatomic variations in the right upper limb of a 45-year-old cadaver. The anomalies were superficial ulnar artery, persistent median artery, variant superficial palmar arch, third head for biceps brachii, accessory head for flexor pollicis longus, variant insertion of pectoralis major, absence of musculocutaneous nerve, coracobrachialis muscle supplied by lateral root of median nerve and anomalous branching of median nerve in arm and forearm. Although there are individual reports about these variations, the combination of these variations in one cadaver has not previously been described in the literature consulted. Awareness of these variations is necessary to avoid complications during radiodiagnostic procedures or surgeries in the upper limb.

Corresponding author: Venkata Ramana Vollala, e-mail: ramana.anat@gmail.com

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21. Superficial peroneal nerve lipoma

J. Terrence Jose Jerome

Lipoma is one of the most common benign soft tissue tumors. The most common location of lipomas is in areas of abundant adipose tissue. Lipomas arising in the peripheral nerves are rare tumors, with most arising in the forearm and wrist, and most have occurred within the median nerve. This report describes a case with lipoma arising in the superficial peroneal nerve.

Corresponding author: J. Terrence Jose Jerome, MD, MBBS, DNB (Ortho), MNAMS (Ortho) FNB (Hand & Microsurgery), e-mail: terrencejose@gmail.com

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22. Peculiar tendinous origin of the brachialis muscle: anatomic and clinical insight

Vandana Mehta, R. K. Suri, Jyoti Arora, Gayatri Rath, S. Das

The current study seeks to elucidate the presence and potential function of an anomalous tendinous origin of the brachialis muscle. The brachialis muscle originates from the humeral shaft, which is usually muscular, thereby becoming tendo-aponeurotic distally towards its insertion. During routine cadaveric dissection, in a 52-year-old cadaver, the anomalous brachialis muscle originated in the form of a tendon measuring 4.4 cm in length. The tendon was attached to the proximal humeral shaft near the lateral lip of inter-tubercular sulcus. The aponeurotic insertion was as usual, into the ulnar coronoid process. The long tendinous origin of the brachialis muscle as observed in the present study could alter the biomechanics of the muscle. A long tendinous origin of the muscle may predispose to frequent tendinous injuries. There are possibilities of the anomalous tendon being used as a graft in elbow injuries. A comprehensive knowledge of such a rare anatomical variation could prove beneficial in surgical, rehabilitation and radiological field.

Corresponding author: Vandana Mehta, MBBS, MS, e-mail: drvandanamehta@gmail.com

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23. Unusual communication between the lingual nerve and mylohyoid nerves in a South Indian male cadaver: its clinical significance

Bhagath Kumar Potu, Thejodhar Pulakunta, Biswabina Ray, Muddanna S. Rao, K. M. R. Bhat, Suhani Sumalatha D'Silva, S. R. Nayak

It is well known that variations in the branching pattern of the mandibular nerve frequently account for the failure to obtain adequate local anesthesia in routine oral and dental procedures, and also for the unexpected injury to branches of the nerves during surgery. During our routine dissection, we found the presence of a communicating branch between the mylohyoid and lingual nerves in a middle aged male cadaver. We also discussed its clinical and surgical implications in this report.

Corresponding author: Bhagath Kumar Potu, e-mail: potukumar2000@gmail.com

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