ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 53 No. 3 Suppl., 2012
This supplement was not sponsored by Outside Organizations.

1. Combined two-photon laser-scanning microscopy and spectral microCT X-ray imaging to characterize the cellular signature and evolution of microstroke foci

F. Kirchhoff, F. Debarbieux, Carine Kronland-Martinet, G. R. Cojocaru, A. Popa-Wagner

Occlusive brain ischemia and micro-strokes are the most frequent brain pathologies, particularly in older patients and a major cause of dementia. Currently, we are missing appropriate methodology to study micro-strokes in experimental animals. In vivo two-photon laser-scanning microscopy (2P-LSM) and transgenic mouse models expressing cell type specific reporters have been used to examine ischemia-related insults, e.g. perturbations of neuronal process morphology and local blood flow in the MCAO - middle cerebral artery occlusion-model. Glia and pericytes can be visualized by selective fluorescent protein expression, e.g. astrocytes by their cyan-fluorescent ECFP, pericytes by red-fluorescent tdtomato and microglia by green fluorescent EGFP expression. In these mice, the breakdown of the blood brain barrier and the immediate as well as long-term cellular responses can be monitored. A new prototype of microCT incorporating a fast X-ray XPAD3 camera has been recently set up to allow cerebral angiography at high sampling rate. Preliminary data indicate that it is useful to monitor blood perfusion disturbance (i.e. lateralization) in the brain of tumor-bearing mice following retro-orbital injection of iodinated contrast agent. We expect this technology to be adequate to assess in real time the impact of acute stroke models on brain blood perfusion. By localizing perfusion anomalies, we will evaluate the extent of non-perfused areas and correlate these observations with subsequent behavioral deficits, and with local changes in myelin content in white matter tracks. The spectral properties of the XPAD3 detector moreover allow for the simultaneous identification and localization of several contrast agents opening the way to whole body multicolor imaging of vessels and inflammatory cells in the context of microstrokes.

Corresponding author: Aurel Popa-Wagner, MD, PhD; e-mail: aurel.popa-wagnerap@med.uni-rostock.de

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2. Histological aspects of post-TACE hepatocellular carcinoma

Corina Gabriela Cotoi, Shirin Elizabeth Khorsandi, I. E. Plesea, A. Quaglia

Hepatocellular carcinoma (HCC) is the fifth most common type of cancer in men and the seventh in women and is the third most common cause of death from cancer worldwide [http://globocan.iarc.fr]. The overall incidence of HCC remains high in developing countries and is steadily rising in most industrialized countries [Shariff MI et al., 2009]. A variety of therapeutic modalities is available for treating hepatocellular carcinoma, but orthotopic liver transplantation (OLT) represents a curative option. Due to the shortage of donor organs and the increasing need for liver transplantation in the last decade, local ablation therapy (LAT) has been increasingly used in many centers as a bridge to transplant [Majno PE et al., 1997; Decaens T et al., 2005; Herber S et al., 2005; Bharat A et al., 2006; Obed A et al., 2007; Otto G et al., 2007]. We retrieved from the archive in the Histopathology Laboratory, Institute of Liver Studies, Kingâ??s College Hospital, London, UK, 28 cases of HCC, which underwent treatment with TACE (Doxorubicin 40 mg/m2) as a bridge to transplantation, between 2008 and 2010. We also analyzed 14 additional post-TACE tumors, classified according to the architectural patterns published by Morisco F et al. (2008), for quantification of necrosis. Extensive tumor necrosis was observed in 12 (42.85%) of the patients. Viable hepatocellular carcinoma showed a wide range of differentiation, from well to poorly differentiated. The phenotype of the tumors was mostly hepatocelluar, but 14% showed a mixed phenotype, including glandular/pseudoglandular formation and cholangiocellular components. The percentage of necrosis ranged between 0% and 100%, with an average of 50.6%. There was no statistical correlation between the total size of the nodules and the surface of necrosis in our series (p=0.125). In conclusion, the systematic pathological assessment of post-TACE resected HCC can help in investigating the biology of treated tumors but needs to incorporate sampling protocols, digital image analysis, phenotypic classification by immunohistochemistry and enzymatic function.

Corresponding author: Corina Gabriela Cotoi, Clinical Research Fellow; e-mail: corina.cotoi@nhs.net

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3. Immunohistochemical expression of TGF beta (TGF-beta), TGF beta receptor 1 (TGFBR1), and Ki67 in intestinal variant of gastric adenocarcinomas

Anca Oana Docea, P. Mitrut, Diana Grigore, D. Pirici, Daniela Cornelia Calina, Eliza Gofita

Although in the last decades the incidence of gastric cancer declined, at present it is ranked worldwide on the fourth place between all human cancer pathology. Also, it has an aggressive behavior, the majority of patients being diagnosed in advanced stages. One of the key factors to control survival improvement of those patients is to clarify the molecular mechanisms involved in initiation, progression, invasion, and metastasis of gastric cancer. We thus investigated the immunoreactivity for TGF-beta, TGFBR1, and Ki67 of 25 specimens of intestinal gastric adenocarcinomas, and compared this with the correspondent reactivity for three specimens of diffuse gastric carcinomas; in the end, we tried to establish a statistical correlation with major clinicomorphological parameters. As a result, we noticed that the highest reactivity was present in the diffuse type compared with the intestinal variant, in which the TGF-beta reactivity progressively increased along the normal epithelium-intestinal metaplasia-dysplasia-carcinoma sequence. Also, we found for intestinal variant that TGF-beta immunoreactivity correlated significantly with tumor degree of differentiation and proliferative activity measured based on Ki67 immunoreactivity. In conclusion, TGF-beta is implicated in the progression of intestinal type of gastric adenocarcinomas and its immunoreactivity assessment for these targets has a prognostic value.

Corresponding author: Daniel Pirici, University Assistant, MD, PhD; e-mail: daniel.pirici@ua.ac.be

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4. Role of innate immune receptors TLR2 and TLR4 as mediators of the inflammatory reaction in human visceral adipose tissue

Ana Marina Fusaru, Camelia Elena Stanciulescu, V. Surlin, C. Taisescu, Adriana Bold, O. T. Pop, Ileana Monica Banita, Stefania Craitoiu, Catalina Gabriela Pisoschi

White adipose tissue from different locations is characterized by significant differences in the structure of adipocyte "secretoma". Fat accumulation in the central-visceral depots is usually associated with a chronic inflammatory state, which is complicated by the metabolic syndrome. Recently, the adipose tissue was emerged to have an essential role in the innate immunity, adipocytes being considered effector cells due to the presence of the Toll-like receptors (TLRs). In this study, we compared the expression of TNF-alpha, TLR2 and TLR4 in peripheral-subcutaneous and central-peritoneal adipose depots in three different conditions - lean, obese and obese diabetic - using immunohistochemistry. Our results suggest a correlation between the incidence of the stromal vascular cells and adipocytes TNF-alpha and TLR4 in the visceral depots in strong correlation with adipose tissue expansion. TLR2 positive cells were seen in the peripheral depots from all groups without any association with fat accumulation. These results focus on the existence of a new pathogenic pathway, the activation of TLR4, for the involvement of visceral adipose tissue in the activation and maintenance of the inflammatory cascade in obesity.

Corresponding author: Catalina Gabriela Pisoschi, Professor, PhD; e-mail: c_pisoschi@yahoo.com

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5. Correlations between morphological appearance and psychosocial difficulties in patients with extensive burns who received allotransplant

D. R. Calota, C. Nitescu, S. Marinescu, Carmen Cristescu, Ileana Boiangiu, I. P. Florescu, I. Lascar

Extensive burns are devastating traumatic events, with significant potential for development of complex psychosocial problems. The aim of the study was to identify and quantify these difficulties among extensive burns patients. This study was conducted at Clinical Emergency Hospital for Plastic, Reconstructive and Burns Surgery and "Bagdasar-Arseni" Emergency Hospital, in Bucharest, on 43 extensive burn patients. For each patient we developed a statistic sheet with demographic data and medical information. For data collection, subjects completed the following instruments: Hamilton Depression Scale (HAMD) and Satisfaction With Appearance Scale (SWAP). The impact variables evaluated in this study were demographic characteristic of patients, burn injury characteristics, abnormal scarring and visible scars, body image dissatisfaction and depression symptoms. Although performed on a small sample, the results of this pilot study could be a valuable starting point for future larger studies, to achieve more generalizable results on extensive burns survivor's quality of life.

Corresponding author: Dan Radu Calota, MD, PhD; e-mail: dcalota@yahoo.com

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6. Implications of tubulo-interstitial epithelial and mesenchymal relation in chronic kidney disease

Ofelia Jercan, M. Penescu, Diana Maria Trasca

Introduction: Several studies have shown the prognostic value of markers detecting interstitial infiltration, epithelial-mesenchymal transition (EMT) and tubulo-interstitial damage in chronic kidney disease evolution. Aim of our investigation was to further evaluate the pathological correlation of such parameters in a population with chronic kidney disease in early stages. Materials, Methods and Results: In a population of 16 patients, with a prior diagnosis of chronic kidney disease in early stages, that underwent a biopsy procedure for clinical indication, there were evaluated the expression in kidney tissue of mesenchymal, epithelial and proliferation markers. Material remaining after routine light microscopy and immunofluorescence was stained for mesenchymal markers such as vimentin, epithelial markers such as cytokeratin and E-cadherin. Quantitative evaluation was conducted by electronic image analysis on consecutive low power fields, avoiding glomeruli, and estimated as percentage of the total area. The clinical and biochemical characteristics evaluated during the hospitalization period showed the prevalence of multiple cardiovascular risk factors such as: arterial hypertension (68%), abnormal blood lipid levels (32%), obesity (27%), diabetes (19%). The histopathological characteristics of chronic kidney dysfunction was related with higher expression of mesenchymal markers (p<0.001) and a decrease expression of epithelial markers (p=0.003). Conclusions: The interrelation of epithelial and mesenchymal tubulo-interstitial markers was demonstrated even in early stages of chronic kidney dysfunction.

Corresponding author: Ofelia Jercan, MD, PhD student; e-mail: ofeliajercan@gmail.com

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7. Current data in clinicopathological characteristics of primary hepatic tumors

S. Turdean, Simona Gurzu, M. Turcu, S. Voidazan, Anca Sin

Aim: The present study aimed to investigate the status of primary liver tumors diagnosed in the Emergency Hospital of Mures County, Romania. Materials and Methods: We performed a retrospective study based on data collected from histopathological bulletins stored in the archives of the Pathology Laboratories of Mures County. We selected those patients' data that were diagnosed with liver tumors during January 2004-August 2011. The acquired data were collected and processed statistically using the GraphPad InStat Demo 3 statistical software. Results: We identified 748 liver tumors out of which 264 were primary liver tumors (35.29%), whereof 108 were malignant primary liver tumors and 156 benign liver tumors. The male:female ratio in case of malignant tumors was 1.7:1 and for benign tumors it was 1:2.62. In case of malignant tumors, the mean age of male patients was 63.98+/-11.67 as for female patients it was 60.14+/-11.65 years. In case of benign tumors, the mean age of male patients was 59.29+/-9.58 as for female patients it was 55.55+/-12.86. 81.48% of the malignant tumors were hepatocellular carcinoma (HCC), followed by cholangiocarcinoma (14.81%). 40% of HCC presented associated cirrhosis, in the other 60% signs of chronic alcoholism being observed. Conclusions: Hepatocellular carcinoma remains the first on the list of malignant primary liver tumors in Romanian patients, probably due to a high rate of alcohol consumption.

Corresponding author: Simona Gurzu, Senior Lecturer, MD, PhD; e-mail: simonagurzu@yahoo.com

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8. Microscopic aspects of pulpal changes in patients with chronic marginal periodontitis

O. Caraivan, H. Manolea, Dorina Corlan Puscu, A. Fronie, Adina Bunget, L. Mogoanta

Chronic periodontitis is one of the most frequent and severe diseases involving the tooth. Untreated, they can lead to tooth loss. Our study involved 67 patients with chronic marginal periodontitis who underwent tooth extraction, of which 29 had moderate periodontal lesions and 38 severe periodontal lesions. The microscopic study of the dental pulp revealed significant changes in all patients. In patients with moderate periodontitis the pulp tissue was found to be the site of an enhanced process of collagenous fibrosis associated with a moderate inflammatory infiltrate, dystrophic mineralization, reduced blood vascularization and arteriolosclerosis. The dental pulp of patients with severe periodontitis showed an abundant chronic inflammatory infiltrate associated with pulpal necrosis, vascular congestion, microhemorrhages, dentin demineralization and odontoblast impairment.

Corresponding author: Laurentiu Mogoanta, Professor, MD, PhD; e-mail: laurentiu_mogoanta@yahoo.com

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9. E-cadherin expression in invasive ductal carcinoma associates ultrastructural changes in desmosomes structure

Carmen Elena Cotrutz, H. Abuelba, Doinita Olinici, T. Petreus

The relationship between E-cadherin presence/absence and the integrity of the desmosomes at the same level becomes important regarding the discrepancies between E-cadherin lack of expression in severe invasive carcinomas and the desmosome activity. Purpose: In the present study, we have evaluated the presence of E-cadherin (EC) in 34 cases of metastatic or non-metastatic invasive ductal breast carcinomas (IDC) by immunohistochemistry followed by transmission electron microscopy (TEM) evaluation on samples prepared from paraffin sections. Materials and Methods: Our study has analyzed 34 paraffin blocks incoming from 20 cases with documented presence of metastatic invasion and 14 cases without metastases. All samples were processed and stained by classic Hematoxylin-Eosin, immunohistochemistry to detect EC presence and transmission electron microscopy. Results: Our results, even on a small pilot group, emphasize that EC presence is associated with the complete desmosomal integrity in non-metastatic cases, at least for the investigated areas. From the metastatic IDC cases, we have observed reduced EC expression in only three cases and important loss of desmosomal arrangement, mainly at the desmosomal plate level. Conclusions: This observation can issue the hypothesis that even in IDC cells that express EC, the invasive potential depend not only on EC-dependent junctions but also on the desmosome integrity. Also, correlated relationship between EC expression, potentially explored desmogleins, desmocollin, desmoplakin and plakoglobin expression and TEM ultrastructure can lead to a conclusion about the invasive potential of these malignant cells.

Corresponding author: Hussam Abuelba, MD, PhD student; e-mail: dr_husam75@yahoo.com

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10. Correlations between colposcopy and histologic results from colposcopically directed biopsy in cervical precancerous lesions

Ancuta Boicea, Anca Patrascu, V. Surlin, D. Iliescu, M. Schenker, Luminita Chiutu

Introduction: Cervical cancer develops from well-defined precursor lesions in a varied period of time. Detected in early or pre-invasive stages, cervical cancer is preventable and curable, so detection of precancerous lesions is very important. Colposcopy with directed biopsy is used in the evaluation and management of patients with cervical lesions, and described as the 'gold standard' for the diagnosis of cervical precancer. Aim: The aim of this study is to assess the accuracy of colposcopic examination and cervical punch biopsy, to determine the correlation between these two methods. Materials and Methods: We examined 245 patients who present malignant findings at colposcopy and biopsy. Colposcopic findings in our study group: 28 (11.4%) cases were CIN I, 50 (20.4%) cases were CIN II, 150 (61.2%) cases were CIN III, 13 (5.3%) cases were micro-invasive carcinoma and four (1.6%) cases were CIS. Histological results in the 245 examined cases were: four (1.6%) cases normal, 26 (10.6%) cases CIN I, 55 (22.4%) cases CIN II, 138 (56.3%) cases CIN III, 15 (6.1%) cases micro-invasive carcinoma and seven (2.8%) cases of CIS. Results: The correlation was 78.5% in the CIN I category, 84% in the CIN II category, 88.6% (133 out of 150 patients) in the CIN III category, 46.1% for micro-invasive carcinoma and 50% for CIS. The colposcopy method incurred fewer false negatives (four patients), giving a general accuracy rate of 98.3%. Sensitivity of colposcopic examination was 83.6%. Conclusions: This study demonstrated high accuracy and correlation between colposcopy and histology, comparable with results from similar studies in the literature. Sensitivity is lower, probably because biopsies were done in all cases, during diagnostic work-up. We also demonstrated the usefulness of these two diagnostic procedures as screening tests in preclinical cervical cancer. In our study, there were cases of under or over diagnose; the benefit of colposcopy and directed biopsy is to avoid over treatment of low-grade lesion, and under treatment of high-grade lesion.

Corresponding author: Ancuta Boicea, MD, PhD resident; e-mail: ssm11ssm@yahoo.com

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11. Endometrial proliferative lesions associated with uterine fibromatosis

Anca Daniela Braila, Diana Vaniova Klimentova, C. M. Damian, M. B. Braila

Hysteroscopy and uterine curettage are required in cases of atypical hyperplasia in premenopause and in all cases of hyperplasia with/without atypia in postmenopausal women. Biopsic curettage is the method of choice in the diagnosis of endometrial pathology. Transvaginal ultrasound and Doppler examination are useful in assessing the risk of endometrial hyperplasia or endometrial cancer in postmenopausal women without/with continuous replacement therapy, but cannot replace endometrial biopsy to exclude endometrial cancer diagnosis. Medical treatment with progesterone containing drugs addresses endometrial hyperplasia without atypia. Surgical treatment is recommended for premenopausal and postmenopausal patients with uterine fibromatosis associated with atypical hyperplasia as well as patients with adenocarcinoma. Risk of progression to malignancy requires clinical and histopathological monitoring to avoid insufficient treatment of lesions with evolutive risk and aggressive treatment of lesions without risk.

Corresponding author: Anca Daniela Braila, Teaching Assistant, MD; e-mail: ancabraila@yahoo.com

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12. The characterization of PDGFR-alpha and PDGFR-beta expression in malignant non-Hodgkin lymphoma

Adina Octavia Duse, Raluca Amalia Ceausu, T. Mezei, Anca Maria Cimpean, Pusa Gaje, Hortensia Ionita, I. Jung, M. Raica

PDGF receptors play an important role in tumor progression as being part of a group of receptors that are expressed along the membrane of tumor cells. The aim of this study was to evaluate the PDGF receptor expression in follicular and diffuse forms of non-Hodgkin malignant lymphoma. We evaluated 38 biopsy fragments from patients diagnosed with malignant non-Hodgkin lymphoma. We noticed the distribution of PDGFR-alpha and -beta in tumor cells and the immunoreactivity was quantified as the percentage of positive tumor cells. We noticed the presence of score 3, more than 30% of tumor cells positive, for PDGFR-alpha and PDGFR-beta in 50% and 75% cases of follicular non-Hodgkin lymphoma. For diffuse malignant non-Hodgkin lymphomas, score 3 was noted in 23.52% of cases for PDGFR-alpha and 35.29% of cases for PDGFR-beta. This may represent an important therapeutic target in patients who do not respond to conventional therapy, but further research is needed for a careful evaluation of benefits and side effects of PDGFR inhibitors.

Corresponding author: Adina Duse, MD, PhD student; e-mail: adinadusche@yahoo.com

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13. Negative estrogen-receptor invasive breast carcinoma: mammographic aspects, correlations with HER2/neu oncoprotein status

Dana Elena Enache, Claudia Valentina Georgescu, Nicoleta Patrana

This study involved 40 ER-negative female patients with invasive breast cancer, aged between 25 and 88 years, diagnosed at Emergency County Hospital of Craiova, Romania, during a two-year interval (2010-2011). All patients that took part in the study were subjected to a preoperative mammography exam, and later to HP and IHC exams, in order to detect the ER, PR and HER2 status. These exams were followed by CISH in ambiguous HER2 cases. The tumor detection method was palpation in 16 cases, whereas in 24 cases the method used was the screening mammography. Histopathologically, the analyzed tumors were infiltrative ductal carcinoma (35 cases), lobular carcinoma (one case), mucinous (two cases) and metaplastic carcinoma (two cases). Depending on the status of the oncoprotein HER2, the 40 ER-negative female patients included in the study formed two groups: the ER-negative, HER2-positive (11 cases, 27.5%) formed the first group and the ER-negative, HER2-negative (29 cases, 72.5%) formed the second group. Depending on the expression of the receptors for progesterone, 60% of cases were classified as triple negative mammary carcinomas (ER-, PR-, HER2-). The comparative study of the ER-negative, HER2-positive and the ER-negative, HER2-negative mammary carcinomas showed that the tumors of the ER­negative, HER2-positive group were mostly high degree cancers (80% vs. 56%), with negative progesterone receptors (81.81% vs. 48.27%), associated with axillary lymph node metastasis (63.63% vs. 48.27%), and were detected at a higher cancer stage (II/III) (81.81% vs. 62.06%). Regarding the mammographic features, the ER-negative HER2-positive breast cancers are more likely to be irregular masses (62.5% vs. 33.33%), with spiculated margins (45.45% vs. 6.9%), frequently associated with dense or heterogeneously dense breast (82% vs. 69%) and pleomorphic calcifications (62.5% vs. 28.57%) comparative with ER-negative HER2-negative cancers that were more frequently round/oval mass, with indistinct margins and a great variety of morphological types of calcifications. The correlations between imaging and clinical aspects, together with the biomarker expression in breast cancers may sooner suggest the biological characteristics of these tumors, thus hinting at their evolution and helping to identify female patients with invasive breast cancer that will positively respond to an aimed therapy.

Corresponding author: Dana Elena Enache, PhD candidate; e-mail: danaenache1979@yahoo.com

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14. Morphometric findings in avascular necrosis of the femoral head

Diana Kamal, Rodica Traistaru, D. O. Alexandru, C. K. Kamal, D. Pirici, O. T. Pop, D. Gh. Malaescu

Avascular necrosis of the femoral head is an illness with a controversial etiology, the trigger event being the suppression of blood flow to the femoral head. The disease affects mostly young adults within their third and fifth decade, the majority of the patients being men. The main risk factors are trauma, chronic alcohol consumption, smoking, corticotherapy. The main goal of our study is to describe the morphometric changes found in the bone tissue of patients diagnosed with avascular necrosis of the femoral head, with different risk factors, by comparing the area of bone trabeculae inside the area of necrosis with that from the adjacent viable tissue. The morphometric study used biological material from 16 patients with ages between 29 and 57 years, who underwent surgery for avascular necrosis of the femoral head. They were admitted in the Orthopedics Department at the Emergency County Hospital in Craiova between 2010 and 2011 and were split into four groups. Group I presented trauma as the main risk factor, Group II had corticotherapy as the defining risk factor, Group III presented chronic alcohol consumption and Group IV was represented by the patients who smoked and exhibited chronic alcohol consumption. There was not a significant statistical difference between the areas of bone trabeculae of the four groups when we compared viable bone tissue to the necrotized one. Knowing the risk factors of the avascular necrosis of the femoral head is critical to the management of the disease, because diagnosing it in an early stage is a necessity for obtaining a good result for conservative treatment.

Corresponding author: Rodica Traistaru; e-mail: rodicatraistru@hotmail.com

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15. Indications and limitations of histopathological skin investigation of Henoch-Schonlein purpura in children

Alina Murgu, Doina Mihaila, Lorette Cozma, Ana Maria Chiforeanu

Henoch-Schonlein purpura, the most common primary vasculitis of the child, may cause, in some cases with atypical clinical picture, diagnostic difficulties with a significant prognosis impact, especially when occasionally "silent" renal symptoms coexist. The purpose of our study is, on one hand, to determine the histopathological investigation needs of Henoch-Schonlein purpura in children with atypical cutaneous manifestations or incomplete forms of illness and, on the other hand, to point out the correlation between the cutaneous histopathological aspects and other clinical and biological manifestations. Results: Optical microscopy revealed signs of leukocytoclastic vasculitis in 11 of the 22 cases with ulcerative necrotic purpura and atypical clinical picture. Immunohistochemical examination proved that these were associated with IgA deposits on the vascular wall, sometimes accompanied by C3, fibrin, IgM and CD3. The severity of the skin manifestations was directly correlated with the severity of digestive and/or renal symptoms. Conclusions: Skin biopsy is indicated only in the atypical or incomplete forms of disease to support positive diagnosis by immunohistochemical evidence of the vascular IgA deposits. The severity and persistence of the ulceronecrotic purpuric rash seems to be directly related rather to the severity of the other clinical manifestations (digestive or renal) than to the generalized extensively purpuric appearance.

Corresponding author: Alina Murgu, Assistant Professor, MD; e-mail: m_alina_66@yahoo.com

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16. A radiographic study regarding post retained restorations

Vanda Roxana Nimigean, Lavinia Butincu, V. Nimigean

The aim of this study was to evaluate the incidence of intraradicular retention and the prevalence of different types of posts used for the restoration of endodontically treated teeth, in clinical practice. Materials and Methods: The study was performed on 94 digital panoramic radiographies that allowed a comprehensive appreciation. Root canal fillings and the posts were identified on these radiographies and their correctness and quality were assessed by measurements according to the data provided by the specialized literature references. Morphologic parameters investigated were: length, diameter and configuration. Results: 474 teeth with endodontic treatment were identified, of which 224 were post restored: 156 (69.6%) using cast posts, 55 (24.6%) using prefabricated non-metallic posts and 13 (5.8%) using threaded prefabricated metallic posts. Regardless the type, we have noticed a great number of errors (84.37%) concerning the manufacturing, the selection, or the application of the post. The errors resulted from disregarding at least one of the investigated morphologic parameters. Intraradicular retention is indicated in clinical situations were dental tissues destruction does not allow placement of crown fillings. Conclusions: The improvement of endodontically treated teeth restorations retention with posts is appropriate as long as post preparation does not undermine the remaining tooth structure. Scientific debates still exist regarding the safest modality to restore a non-vital tooth.

Corresponding author: Victor Nimigean, Professor, PhD; e-mail: victornimigean@yahoo.com

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17. Invasive mammary carcinoma: assessment of HER-2/neu status by immunohistochemistry

Nicoleta Patrana, Claudia Valentina Georgescu, Georgiana Luminita Fota, Dana Elena Enache, Elena Pirici

HER-2/neu oncoprotein overexpression in breast cancer patients has an impact on prognosis and treatment methods so assessment of its status is therefore much needed. The study group consisted of 90 cases of mammary invasive carcinoma. The distribution of HER-2/neu immunoexpression for scores 0, 1+, 2+ and 3+ were 54.44%, 11.11%, 18.8% and 15.56% respectively. HER-2/neu-positive cases comprised 21.42% of patients less than 50-year-old compared to 14.47% of patients of 50-year-old or older. Tumor size was negative correlated with HER-2/neu immunoexpression: positive tumors comprised 37.5% of tumor larger than 5 cm and this percentage decreases with tumor dimension to 2.94% in tumors of 2 cm or less. Regarding the histopathological subtype of invasive mammary carcinoma, only some types were positive, like 17.57% of IDC NOS and one case of mixed ductal-lobular invasive carcinoma. The highest proportion (21.31%) of positive HER-2/neu cases presented high-grade carcinomas (GIII), comparing with well-differentiated (GI) that were all negative. Regarding the axillary lymph node status the lowest proportion of positive HER-2/neu cases was 4.54% in the absence of metastasis, and rises to 34.78% in cases with more than three axillary lymph nodes involved. HER-2/neu-positive tumors showed a low incidence of ER+ or PR+ cases unlike HER-2/neu-negative cases (35.71% vs. 83.05% for ER, respective 21.42% vs. 76.27% for PR). Therefore, in conclusion, HER-2/neu-positive tumors are significantly fewer than the negative ones, but these are found in younger women and are associated with: large tumor size, high grade of malignancy (GIII) and increased number of axillary lymph node involvement. HER-2/neu immunoexpression is related to histological subtype of invasive breast carcinomas. Hormonal status is negative related to HER-2/neu expression.

Corresponding author: Nicoleta Patrana, MD; e-mail: nicoleta_patrana@yahooo.com

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18. The relevance of circadian rhythms disruption on pulmonary SOD expression in rat

Raluca Oana Temneanu, A. Motoc, F. E. Zugun, Roxana Folescu, Catalina Elena Lupusoru, Carmen Lacramioara Zamfir

The light-dark cycle represents a significant component of the circadian system in most mammals. Any disturbance of this cycle is reflected in a large number of changes in the physiological and also behavioral status of the organism, together with considerable alterations of the redox balance. Increasing evidence suggests that reactive oxygen species (ROS) have their own function in the circadian system. Superoxide dismutases (SOD) family represents the first prompt antioxidant enzymatic system, identified in all aerobic organisms and able to counteract ROS toxicity; there are three distinct isoenzymes: CuZn-SOD (SOD1), Mn-SOD (SOD2), and extracellular EC-SOD (SOD3). In the case of circadian disruption, when ROS production is enhanced, the impact of the oxidative aggression on superoxide dismutases (SOD) rhythmicity and distribution is still unclear. To estimate the influence of circadian rhythms disruption on pulmonary SOD, we exposed male Wistar rats to continuous light stimuli for four weeks and then investigated the SOD immunohistochemical expression in lungs, which are among the most sensitive organs to oxygen. CuZn-SOD, Mn-SOD and EC-SOD presented a particular immunoreactivity in the investigated pulmonary tissues. These findings support our viewpoint that there is a direct correlation between the rhythmicity of circadian cycles and pulmonary SOD expression.

Corresponding author: Carmen Lacramioara Zamfir, Professor, MD, PhD; e-mail: zamfircia@yahoo.com

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19. Immunoexpression of Ki67 and cyclin D1 in oral squamous carcinomas

D. A. Olimid, Cristiana Eugenia Simionescu, Cl. Margaritescu, Alma Florescu

In this study, we analyzed Ki67 and cyclin D1 immunoexpression in 44 oral squamous cell carcinomas from various anatomical sites. Ki67 immunoreaction was identified in all analyzed cases and presented an index of proliferation of 22% for well-differentiated carcinomas, 32% for moderately differentiated and 53% for the poorly differentiated ones. In case of cyclin D1, the mean positivity index was 8% for well-differentiated carcinomas, 18% for moderately differentiated and 34% for the poorly differentiated carcinomas. The analyzed biomarkers prove useful to identify lesions with poor differentiation and invasive behavior.

Corresponding author: Cristiana Simionescu, Professor, MD, PhD; e-mail: csimionescu2004@yahoo.com

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20. P53 and Ki67 immunoexpression in mucinous malignant ovarian tumors

C. K. Kamal, Cristiana Eugenia Simionescu, Cl. Margaritescu, A. Stepan

Ovarian cancer is the fourth cause of death by cancer among women and the first mortality cause in gynecological neoplasia. Our goal was to evaluate p53 and Ki67 immunoexpression and also the correlations with tumor stage and type. The study included 45 primary ovarian malignant mucinous tumors, diagnosed in patients in the IV and VI decade. From the standpoint of histopathology, there were 28 cases of borderline mucinous tumors and 17 mucinous carcinomas, predominantly stage I of the disease. The immunostaining for Ki67 was positive in all the cases, the highest levels being recorded in mucinous carcinomas (22.2% medium index) compared to the borderline tumors (9.5% medium index). Opposed to Ki67, the immunoreaction for p53 was present in 37.7% of all the tumors, predominantly in mucinous carcinomas where the stain has high values (52.3% medium index) in contrast with borderline lesions (15.5% medium index). The study indicated significant differences in p53 and Ki67 immunostain in relation to the tumor stage and histological type, there being a direct correlation of the expression of both proteins, in the studied tumors. P53 and Ki67 are useful markers for evaluating aggressive tumoral behavior and differentiating between mucinous carcinomas and borderline mucinous tumors.

Corresponding author: Cristiana Simionescu, Professor, MD, PhD; e-mail: csimionescu2004@yahoo.com

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21. The evaluation of the immunoexpression of Her2/neu oncoprotein in ductal carcinoma in situ in association with invasive ductal carcinoma of the breast

Georgiana Luminita Fota, A. Stepan, Raluca Niculina Ciurea

The identification of breast ductal carcinoma in situ (DCIS) is a factor that increases 8-10 times the risk of developing invasive ductal breast carcinoma (DCI) later. In this study, we evaluated the immunoexpression of the HER2/neu oncoprotein in the DCIS cases associated with DCI, both in situ and in the invasive components. We also studied the Her2/neu immunoreactivity in the cases of DCI having no DCIS association. The positive immunoreactivity (score 3) of the HER2/neu oncoprotein was present in 29 cases of high-grade DCIS having DCI associated, corresponding to the histological types comedo, solid, comedo/solid, and micropapillary. A weak-to-moderate complete membrane staining (score 2+) was determined in five high-grade DCIS and four intermediate-grade DCIS cases, belonging to the types comedo, solid, and micropapillary. The negative immunoreactivity of HER2/neu was identified in 18 cases, most of them being of low grade and belonging to the solid and cribriform types. The invasive component of the analyzed lesions indicated a HER2/neu positive reaction in 50% of lesions having DCI associated and 17.4% of the lesions having no DCIS association. The DCIS-DCI association and the DCIS histological types that were analyzed through the HER2/neu immunoexpression can stand as prognostic factors for the malignant breast lesions.

Corresponding author: Alex Stepan, University Assistant, MD, PhD; e-mail: astepan76@yahoo.com

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22. Invasive papillary carcinoma of the mammary gland: histopathologic and immunohistochemical aspects

Irina Anca Eremia, Maria Ciobanu, T. Tenea, Maria Victoria Comanescu, Stefania Craitoiu

Papillary lesions of the breast, both being and malignant, can prove to be a very challenging diagnosis in histological preparations. This study emphasizes on the importance of immunohistochemistry and in particular, the identification of myoepithelial cells for the correct evaluation of these lesions.

Corresponding author: Irina Anca Eremia, MD, PhD student; e-mail: irinaeremia@yahoo.com

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23. The role of immunohistochemistry in the diagnosis of neoplastic pleural effusions

Mihaela Dinu, Raluca Niculina Ciurea, Mirela Stefan, Ana Claudia Georgescu

Identification of the origin of neoplastic pleural effusion is a major concern in lung pathology. This study followed the diagnostic role of a panel of antibodies that included calretinin, HBME1, D2-40, Ber-EP4, CK5/6, CEA and TTF1, in a total of 37 cases of pleural and lung cancer with tumor-type cytology, later confirmed by histopathology. For mesothelioma, positive staining for calretinin, D2-40 and CK5/6 and negative for CEA and TTF1 were characteristic. For lung adenocarcinomas, we found Ber-EP4, CEA and TTF1 positivity, and calretinin, D2-40 and CK5/6 negativity. Squamous lung carcinomas were positive for Ber-EP4, CK5/6 and CEA and negative for HBME1, D2-40 and TTF1. The panel of antibodies used in this study provides a differential diagnosis between mesotheliomas and lung carcinomas as well as between lung adenocarcinomas and squamous carcinomas.

Corresponding author: Raluca Ciurea, University Assistant, MD, PhD; e-mail: raluca.ciurea@yahoo.com

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24. Residual tumor after primary excision of ductal carcinoma in situ (DCIS), on re-excision specimens

C. C. Nistor-Ciurba

The management of pure ductal carcinoma in situ (DCIS) involves local excision, with or without consecutive radiotherapy, or simple mastectomy. Assessment of the recurrence risk is the essential step in decision-making. The hypothesis of this study was that besides the apparition of true recurrences after prior complete excision there may be also cases with residual disease present distant from the initial excised lesion (more than 2 mm). The last ones could be better considered as being cases of evolving disease. To evaluate the presence of residual disease in the re-excision specimens derived either from mastectomies or wide local re-excisions, a cohort of 102 cases of DCISs, operated in "Prof. Dr. Ion Chiricuta" Oncology Institute, Cluj-Napoca, Romania, between 2000 and 2007, were studied. The presence of residual tumor in re-excision specimens was correlated with high grade of DCIS and with age of the patient (less than 60 years). The analysis of mastectomy specimens revealed that 35.4% of all mastectomies had no residual disease (unnecessary mastectomies). Moreover, 59.8% of them had no residual disease or only close residual disease, virtually curable by simple re-excision. This study suggests that up to 59.8% of mastectomies could be avoided. Important is to select those cases in which avoiding mastectomy may be done assuming an acceptable recurrence risk. The study shows that those cases are from over 60-year-old group and those having histological grade G1. Larger prospective studies are needed to confirm the results of this study.

Corresponding author: Codrut Cosmin Nistor-Ciurba, MD; e-mail: nistorco@yahoo.com

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25. Bony metaplasia in a caecum adenocarcinoma

S. S. Mogoanta, C. Mesina, Liliana Streba, Anca Predescu, Garofita Olivia Mateescu, Gabriela Mutiu, L. Mogoanta

Ectopic bone formation in the digestive tract is a very rare phenomenon in pathology. Most cases of bone metaplasia were found in distal colon tumors, rectum and sigmoid respectively. We present a case of well-differentiated adenocarcinoma of the caecum (the second case of literature) associated with bone metaplasia, which debuted atypical, with symptoms of infectious enterocolitis, in a 72-year-old female patient, with no history of digestive pathology. Highlighting bone metaplasia was achieved by current histological techniques. Patient's evolution was favorable with surgical treatment and chemotherapy.

Corresponding author: Laurentiu Mogoanta, Professor, MD, PhD; e-mail: laurentiu_mogoanta@yahoo.com

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26. A rare case of digestive hemorrhage in an elderly patient: diagnosis and treatment difficulties

Mariana Jinga, C. Jurcut, Florina Vasilescu, G. Becheanu, Simona Hildegard Stancu, L. Ciobaca, G. Mircescu, V. Jinga

Abdominal pain represents one of the most common clinical conditions. However, there are some challenging cases in which an extensive work-up is mandatory for the diagnosis. We present the case report of a 65-year-old man admitted to our department for diffuse abdominal pain, nausea, vomiting, diarrhea, painful joints and rectal tenesmus. He initially had an urticarial rash, followed by palpable purpura involving the lower extremities. The diarrheic stools evolved towards melena. Endoscopic examination of the upper gastrointestinal tract showed hiatal hernia, superficial erosions in the stomach and multiple areas of deep and superficial ulcerations disseminated from the second to the third portion of the duodenum. Terminal ileum intubation at colonoscopy showed redness, edema, swelling, petechiae and ecchymosis, irregular erosions and ulcers. Endoscopic biopsy specimens showed non-specific inflammation. Computed tomography showed moderate ascites, small pleural effusion, mesenteric lymphadenopathy and small bowel wall thickening at the level of the second duodenum, proximal jejunum and segments of ileum. The urine analysis revealed microscopic hematuria with nephrotic range proteinuria, red cells and cellular casts. Therapy with corticosteroids and pulses of cyclophosphamide was started with significant clinical improvement. Three weeks after the first admission, the patient developed an acute peritonitis due to an intestinal perforation and acute mesenteric ischemia of the small bowel. We concluded that the patient had a Henoch-Schonlein type vasculitis with acute mesenteric ischemia and perforation of the small bowel.

Corresponding author: Mariana Jinga, Senior Lecturer, MD, PhD; e-mail: mariana_jinga@yahoo.com

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27. Tuberculosis mesenteric adenopathy and polyserositis

M. Olteanu, Mimi Nitu, Andreea Golli

A 41-year-old female patient was admitted into Surgery Clinic accusing abdominal pain, diarrhea, fever and chills. Based on clinical, biological and imaging data, it was established a diagnosis of pelviperitonitis and it was initiated an antibiotic and anti-inflammatory treatment. As fever and abdominal pain continued, it was decided to go on with surgery that revealed suppurated and perforated mesenteric adenopathy. Pus was sampled for bacteriological exam and also biopsy was performed for pathological exam. The result of pathological exam was suggestive for a specific granulomatous lesion (TB lesion). It was established diagnosis of TB mesenteric adenopathy and it was initiated specific anti-TB treatment according to WHO guidelines. After three, respectively five months of treatment, patient developed a right laterocervical adenopathy that fistulized in both cases, despite the correct treatment administered. No resistant TB strain and no atypical mycobacteria was discovered.

Corresponding author: Mihai Olteanu, MD, PhD; e-mail: m78olteanu@yahoo.com

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28. Biomechanical disorders of foot in multiple sclerosis

M. C. Neamtu, Ligia Rusu, P. F. Rusu, M. Marin, Oana Maria Neamtu

Multiple sclerosis (MS) has a multifactorial etiology located at the interaction point of environmental factors - nutritional, geographic, infectious, etc. - with genetic factors, which confers susceptibility to disease or alters its development. This research presents a case study focused on complex assessment of a patient using clinical and functional assessment, biomechanical gait evaluation using RSScan force plate. Biomechanical parameters (contact area, load, impulse, force, pressure, foot balance) are the parameters that we obtain after force plate measurements. Analyzing the results of the functional assessment, it is found an anatomical functional abnormality with a tendency to increase. Biomechanical tests show an asymmetric gait due to the impact of neurological disorders generated in the proprioceptive system. Global analysis of values (surface contact, pressure, force, load, impulse, active contact area) indicates the fact that there is a tendency to develop a higher pressure in the anterior-medial region of the plant in an attempt to maintain balance. It is a tendency to increase the active contact area in the forefoot region; this increase is explained by the body tendency to develop compensatory mechanisms to maintain balance.

Corresponding author: Marius Cristian Neamtu, MD; e-mail: drcristianneamtu@yahoo.com

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29. Acute pancreatitis: the onset digestive manifestation, in a patient with adult T-cell leukemia/lymphoma

M. Popescu, Viola Popov, G. Popescu, Camelia Dobrea, Aurelia Sandu, V. T. Grigorean, V. Strambu, I. E. Plesea

Acute pancreatitis is a common complication, which occurs with patients suffering from vesicular biliary lithiasis or chronic alcoholism. Hypercalcemia may determine acute pancreatitis, its causes being multiple: primary or secondary hyperparathyroidism, metabolic diseases of the bone, metastatic bone neoplasm, as well as lymphoproliferative syndromes caused by the HTLV-1 virus-adult T-cell leukemia/lymphoma (ATLL). ATLL is a malignant and aggressive lymphoproliferation with the T-cell, associated with the infection caused by the HTLV-1 retrovirus. Organomegaly, cutaneous conditions, and hypercalcemia represent the main characteristics of the disease. From a hematologic point of view, we can notice the atypical lymphocytes (also known as flower cells, due to the shape of their nucleus), with a distinct CD4+ CD25+ phenotype. There have been reported few cases of patients who showed acute pancreatitis in the onset of the disease. We will describe the case of a patient whose diagnosis has not been an easy one, as it showed multiple complications from a very early stage. Conclusions: The atypical onset of ATLL with acute pancreatitis is rarely reported. Its etiology seems to be hypercalcemia but pancreatic infiltration with ATLL cells cannot be ruled out. An attentive investigation of the peripheral blood sample and flow-cytometric tests of peripheral and medullar blood smear are very important for diagnosis. The patient showed from the very beginning severe neurological manifestations which developed to a coma. Causes could have been metabolic as well as CNS infiltration (as shown by the CT examination).

Corresponding author: Valentin Titus Grigorean, Associated Professor, MD, PhD; e-mail: valentingrigorean@gmail.com, grigorean.valentin@yahoo.com

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30. Granulomatous cheilitis of Miescher: the diagnostic proof for a Melkersson-Rosenthal syndrome

Andreea Liana Rachisan, A. Hrusca, D. Gheban, Simona Cainap, T. L. Pop, A. Baican, L. Fodor, N. Miu, Mariana Andreica

Background: The Melkersson-Rosenthal syndrome (MRS) is a very rare clinical entity and its classical form is being characterized by the following triad: facial nerve palsy, swelling of the lips and fissured tongue. However, the monosymptomatic form is more common and the typical manifestation is facial edema and/or enlargement of the lips. Case report: We report a case of monosymptomatic MRS with a positive biopsy of granulomatous cheilitis. Conclusions: In the daily practice as a pediatrician, it is not usual to diagnose a patient as having MRS. We consider that this is partly because of misdiagnosis. We therefore believe that this case report will supply additional information, in the scope of recurrent facial paralysis and orofacial edema in both children and adults.

Corresponding author: Andreea Rachisan, Teaching Assistant, MD; e-mail: andreea_rachisan@yahoo.com

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31. A short story of Victor Hensen and a cell of the internal ear

M. Raica

Cells of Hensen of the internal ear are known from more than 100 years and investigations on their function(s) are still waiting for an answer. They were first described by the German scientist from Kiel, Christian Andreas Victor Hensen. This short historical review gives some details about the life, scientific activity and perspectives opened by the work of Victor Hensen.

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

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