ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 55 No. 2 Suppl., 2014
This supplement was not sponsored by Outside Organizations.

1. The possible mechanisms of tumor progression via CSF-1/CSF-1R pathway activation

Li Huang, Ximing Xu, Yanrong Hao

CSF-1/CSF-1R (colony-stimulating factor-1/colony-stimulating factor-1 receptor) is the primary growth factor regulating the survival, proliferation, and differentiation of cells of the mononuclear phagocytic lineage. Multiple studies have demonstrated that CSF-1/CSF-1R plays a certain role in tumor tissues. CSF-1 binding to CSF-1R through the class III RTKs leads to a series of signal molecules responding to CSF-1 via various signaling pathway. Through these pathways, all signal molecules would promote development of tumor directly or contribute to progress of various cancers indirectly by increasing tumor-associated macrophages, for instance promoting tumor growth, angiogenesis, extracellular matrix breakdown, invasion, and metastasis. Thus, in this paper, we analysis multiple experimental results comprehensively, making a review about the mechanism of CSF-1/CSF-1R promoting tumor progression.

Corresponding author: Ximing Xu, Archiater, Master s Supervisor; Yanrong Hao, Associate Senior Doctor, Master s Supervisor; e-mail: whuxxm@yahoo.com, yanronghao.2008@aliyun.com

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2. Optical coherence tomography as a promising imaging tool for brain investigations

Eugen Osiac, Tudor-Adrian Balseanu, Bogdan Catalin, Laurentiu Mogoanta, Cristian Gheonea, Sorin Nicolae Dinescu, Carmen Valeria Albu, Bogdan Virgil Cotoi, Oana-Sorina Tica, Veronica Sfredel

This paper will review the newest results and directions for the usage of optical coherence tomography as an imaging tool for brain studies, focusing mostly on a rodent model. Together with state of the art in the field, based on some of the most recent work, this paper will include a brief look on some results obtained by our group. Brain injuries and stroke data obtained by optical coherence tomography analyzing will be presented as a possibility of detection and evaluation for affected tissue, using this imaging system.

Corresponding author: Tudor-Adrian Balseanu, Lecturer, MD, PhD; e-mail: adrian.balseanu@webmail.umfcv.ro

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3. Gastrointestinal stromal tumors - a clinical-morphological study on 15 cases

Iancu Emil Plesea, Luminita Chiutu, Silviu Iulian Bordu, Ion Georgescu, Eugen Florin Georgescu, Diana Ciobanu, Nicolae-Dragos Margaritescu, Violeta Comanescu, Raducu Nemes

Aim: The authors present their experience in addressing the gastrointestinal stromal tumors (GIST). Materials and Methods: 15 GISTs operated in the last five years (2008-2013) were analyzed. Results: The preoperative diagnosis was difficult: established by clinical examination and CT in two cases; imagistic accidental discovery in four cases and revealed by evolving complications in nine cases (gastrointestinal bleeding in four cases and bowel obstruction in five cases). CT may be useful in the preliminary estimation of the tumor extent. Tumor location was: stomach four, duodenum one, small bowel seven, and colon three. Pathological examination set the main criteria for assessing the risk of recurrence and indication for adjuvant therapy: the tumor size, the histological type (spindle cell nine, epithelioid four, and mixed two) and the mitosis rate, while the immunohistochemistry examination established the correct diagnosis (positivity for CD117 and CD34) and criteria of aggressiveness (positivity for Ki67). All cases were operated, the surgical procedure being chosen according to the tumor location and stage. Adjuvant therapy with Imatinib 400 mg/day was performed in the 12 cases with high risk of recurrence. The therapeutic outcome was: a postoperative morbidity rate of 13.3%, four patients cured, one local recurrence under Imatinib therapy, a mortality rate of 6.6% and 10 patients in different phases of adjuvant therapy. Conclusions: GIST has been imposed over the last decade as the main type of non-epithelial tumor of the digestive tract. The preoperative imagistic investigations can be very useful for setting the surgical strategy. The improvement of the mitotic index and/or Ki67 labeling index (LI) determination could render more accurate the scales for prognostic assessment. The two steps algorithm - surgery + adjuvant therapy - still remains the only option to make this dangerous condition a curable one.

Corresponding author: Luminita Chiutu, Associate Professor, MD, PhD; e-mail: luminita.chiutu@gmail.com

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4. The diagnostic value of immunohistochemistry and silver impregnation techniques for characterization of normal, reactive and tumoral astrocytes

Alina Simona Sovrea, Adina Bianca Bosca, Carmen Georgiu, Anne-Marie Constantin, Mohamed Amine Ben Abdalah, Dan Gheban

Astrocytes represent a heterogeneous population of specialized glial cells responsible not only for accomplishing various important functions in the healthy nervous tissue, but also for reacting to all types of the central nervous system diseases and trauma. GFAP immunostaining is considered to be the most accurate of the routine techniques used for identifying astrocytes; however, silver impregnation techniques, which are inexpensive and approachable, might be a reliable alternative. The present research has brought into question and tried to assess the sensitivity and specificity of these classical methods for identifying and differentiating normal and reactive from tumoral astrocytes. Our study included 10 supratentorial gliomas specimens of various grade and two normal brain samples. We performed a histological study on consecutive seriated sections labeled using four methods: the immunostaining for GFAP (glial fibrillary acidic protein) and the three silver impregnation techniques: Ramon y Cajal, Bielschowsky-Cajal and Gomori. For each tumoral case, two areas were examined: the tumoral parenchyma and the tumor borders (considered as reactive gliosis) and were both compared to healthy brain parenchyma; for each area, three microscopic fields were assessed and two parameters were recorded: a semi-quantitative score (the astrocytes density) and a qualitative score (the color intensity). We used a complex statistical analysis in order to process the data and to compare the diagnostic value of silver impregnation techniques versus GFAP immunostaining (the reference method) in terms of tumoral grading and differentiating tumoral from normal and reactive astrocytes. Our results indicated that there data provided by both GFAP immunostaining and silver impregnation techniques were comparable.

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

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5. Inducible nitric oxide synthase expression (iNOS) in chronic viral hepatitis and its correlation with liver fibrosis

Daniela-Elise Tache, Camelia Elena Stanciulescu, Ileana Monica Banita, Stefana Oana Purcaru, Ana Marina Andrei, Violeta Comanescu, Catalina Gabriela Pisoschi

Background: Nitric oxide (NO) production by the action of the inducible nitric oxide synthase (iNOS or NOS2) is increased in tissues that are stimulated by cytokine and endotoxins. The role of NO in the pathogenesis of chronic viral hepatitis is not fully understood but it seems that its overproduction is responsible for the pathological changes under inflammatory conditions. Aim: In this paper, we analyzed the correlation between immunohistochemical expression of iNOS and liver fibrosis in chronic viral hepatitis. Materials and Methods: Liver biopsies from patients diagnosed with chronic viral hepatitis B and C were embedded in paraffin and further used for histological staining and immunohistochemical reactions to detect the expression of iNOS and TGF-beta1. The degree of liver fibrosis was established using special staining (trichromic Masson and Gomori s silver impregnation). Results: In samples with low degree of fibrosis, we observed a discrete positivity for iNOS in periportal hepatocytes and the immunohistochemical reaction for TGF-beta1 were limited to the endothelial cells of liver sinusoids and pro-inflammatory cells from the portal tracts. Positive reaction for TGF-beta1 increased with the degree of liver fibrosis, while the expression of iNOS was enhanced in hepatocytes, as well as in bile ducts and endothelial cells. Conclusions: Infection with hepatitis B and C viruses induces iNOS expression in hepatocytes, suggesting that NO overproduction might have an important role in progression of chronic viral hepatitis to cirrhosis._x000D_

Corresponding author: Ileana Monica Banita, Professor, MD, PhD; e-mail: monica.banita@yahoo.com

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6. Silica network improve the effect of fludarabine and paclitaxel on HCT8 cell line

Georgeta Voicu, Adrian Gabriel Anghel, Mihaela Badea, Emanoil Bordei, Georgiana Crantea, Raluca Ionela Gavrila, Alexandru Grecu, Denisa Ana-Maria Jercan, Bogdan Cristian Nicolae, Greta Cristina Vochitoaia, Kuete Tchinda, Alina Maria Holban, Coralia Bleotu, Alexandru Mihai Grumezescu

This paper reports the potential of silica network to sensitize tumor cells and stimulate antitumor toxicity of fludarabine (FLU) and paclitaxel (PAC) against HCT8 cells. SiO2, SiO2/FLU and SiO2/PAC nanostructured materials were characterized by X-Ray Diffraction, Scanning Electron Microscopy, InfraRed Microscopy and in vitro biological assays. When using SiO2/PAC, it can be observed that the cytostatic effect of PAC is boosted only at high concentrations of this material. On the other hand, in the case of SiO2/FLU, data showed an enhancement in the cytostatic activity of FLU by up to 25%, also when using this nanomaterial in low doses. These data represent preliminary study on the impact on silica nano-networks in targeted delivery and controlled release of antitumor drugs and they may be efficiently used for future biomedical applications in cancer therapy.

Corresponding author: Alexandru Mihai Grumezescu, Chem. Eng., PhD; e-mail: grumezescu@yahoo.com

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7. Lymph node tuberculosis - an attempt of clinico-morphological study and review of the literature

Mihai Raul Popescu, Gigi Calin, Irina Strambu, Marian Olaru, Maria Balasoiu, Veronica Huplea, Catalina Zdrancota, Razvan Mihail Plesea, Stelian Danut Enache, Iancu Emil Plesea

Aim: The authors assessed the mycobacterial lesions in the lymph nodes discovered on tissue samples coming from the surgical stage in the Department of Pathology, Emergency County Hospital of Craiova, Romania, starting from 1990 until 2012. Materials and Methods: The studied material consisted of lymph node (LN) tissue samples obtained by biopsy or surgical excision from 362 patients histopathologically diagnosed with tuberculosis. For confirming the diagnosis, Ziehl-Neelsen staining was carried out and, in some cases, PCR technique was used. Results: Patients were mainly women, with a mean age of 35 years. The suspicion of diagnosis at admission was reduced, the most usual diagnosis being a very general and uncertain one of adenopathy/polyadenopathy. In only few cases, other tissues/organs have been affected in the same time with the LN determination. Also, multiple LN group involvement was present in only five cases. The most affected LN groups were: the lateral cervical, submandibular, axillary, inguinal, supraclavicular and mesenteric. In paired LN groups, there was no predilection for any of the body sides. Epithelioid cells (ECs) and giant Langhans cells (GLCs) were present together in most of the granulomatous reactions. However, the presence of neutrophils in 10% of the cases should be noticed. Necrosis was present in almost all cases, displaying the whole range of morphological features, but usually the acidophilic, microgranular one. Fibrosis was rarely encountered. As a whole, well-differentiated granulomas were the most frequent but the presence of hyporeactive granulomas in more than a quarter of the cases and that of non-reactive granulomas in more than 10% of the cases should be noticed. The extension of TB process was not a rare event. Conclusions: LNs seem to be the favorite location of TB besides the lung. The overall morphological picture revealed an active and destructive profile of the bacillary aggression in the LN parenchyma, which could mean either a higher sensitivity of the LN tissue or a more vulnerable background of the patients with TBLN lesions.

Corresponding author: Iancu Emil Plesea, Professor, MD, PhD; e-mail: pie1956@yahoo.com

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8. Cancer stem cells biomarkers in triple negative invasive carcinoma of the breast and associated in situ lesions

Maria Comanescu, Giovanni Bussolati

Triple negative breast cancer (TNBC), negative for expression of estrogen and progesterone receptors (ER, PR) and HER2/neu protein, represent a subtype of breast cancer associated with poor prognosis and highly aggressive behavior. The characterization of stem cell in this type of carcinoma could determine the appearance of new ideas concerning origin and evolution. There is an impressive amount of data in the literature related to TNBC and a growing interest for stem cell research during the past years, but there are no data concerning the genetic characterization of stem cells in the context of cell biology of TNBC as compared with associated DCIS. We performed immunohistochemical studies for the expression and distribution of several stem cell-related antigens, focusing on the association of TNBC with DCIS and comparing the presence of stem cells in the invasive and in the in situ component. Optimization of detection, identification and characterization of tumorigenic breast cancer stem cells might permit further identification of targeted treatment.

Corresponding author: Maria Comanescu, MD, PhD; e-mail: mariacomanescu@yahoo.com

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9. Serum and tumor microenvironment IL-8 values in different stages of colorectal cancer

Maria Balasoiu, Andrei Theodor Balasoiu, Stelian Stefanita Mogoanta, Alexandru Barbalan, Alex Emilian Stepan, Raluca Niculina Ciurea, Dragos Ovidiu Alexandru, Aurelia Enescu, Laurentiu Mogoanta

Introduction: Colorectal cancer represents a major cause of mortality and morbidity and occupies the third place as cancer incidence and the fourth place as cancer mortality. Colorectal cancer causes 608 000 deaths per year, despite correct applied treatment (surgery and chemotherapy). Interleukin 8 (IL-8) is an important proinflammatory cytokine with an important role in leukocyte chemoattraction. IL-8 also represents an important tumorigenic and proangiogenic factor. Materials and Methods: We have studied 68 patients aged between 55 and 70 years, hospitalized in the IInd Surgery Clinic of the Emergency County Hospital of Craiova, Romania. According to TNM grading, the patients were in stages II, III and IV. From these patients, we have prelevated two types of samples: serum and tumor fragment. Results: IL-8 values were significantly increased, both in serum and tumor supernatant. The highest IL-8 values were found in tumor supernatant and in advanced stages; IL-8 increased values were correlated with tumor growth and TNM stage. Conclusions: IL-8 has an important role in colorectal cancer growth and metastasis and represents an important therapeutic target in this type of cancer. IL-8 represents also a predictor for colorectal cancer prognosis.

Corresponding author: Andrei Theodor Balasoiu, MD, PhD student; e-mail: andrei_theo@yahoo.com

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10. Anatomical and histological considerations of placenta vascular diseases with implications in forensic medicine

Roxana Folescu, Andrei Gheorghe Marius Motoc, Carmen Lacramioara Zamfir, Adrian Cosmin Ilie

Placenta, as a highly specialized organ in connecting the maternal and fetal organism, is frequently affected by a specific vascular pathology. The correlation between the macroscopic and the microscopic aspects of the fetal placenta vascularization together with the appearance of fibrin deposits is used to determine the pathological cause of death. Different studies suggest the hypothesis of precocious development of fibrin deposits during pregnancy, due to some immune-like reactions or due to the circulatory variations in the villous territory. The present research was realized on 467 placentas - out of 467 placentas collected in the past 10 years, 287 were from term births, 98 from premature births and 82 from abortions. The fibrin deposits in the placenta resulting from abortion can also be interpreted as alterations caused by the same circulatory variable conditions. In the therapeutic abortion, the placental fragments do not contain fibrin deposits. The correct approach of the macroscopic exam in the vascular pathology, accompanied by the recognition of the microscopic changes in the placenta, contributes to determine the cause of abortion, the premature birth or the term birth, followed by the death of the fetus and/or the mother. The study assesses the macroscopic and microscopic aspects of the vascular pathology at the placental level in cases with medical and legal implications. Our study also reported these placental aspects in aborted fetuses or in cases of intrauterine deaths, for various reasons considered forensic cases.

Corresponding author: Roxana Folescu, University Assistant, MD, PhD; e-mail: roxanafolescu@yahoo.com

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11. Adhesion cell molecules as potential markers of aggressiveness in meningiomas

Dorel Arsene, Maria Comanescu, Carmen Ardeleanu

Routine histopathological criteria are poor predictors of the outcome in meningiomas. The present study tried to determine if some adhesion cell molecules could be helpful in assessing the histological aggressiveness in meningiomas of all grades. Our series comprised 113 cases, WHO grade I (n=53), WHO grade II (n=47) and WHO grade III (n=13). Three cases of meningeal non-meningothelial tumors (hemangiopericytoma, hemangioblastoma and fibrosarcoma) were also studied as control tissue. Immunohistochemistry for CD44, CD54, E-cadherin, progesterone receptor (PGR) and Ki67 was performed. CD54 was for the first time systematically assessed in meningiomas of all three grades of malignancy. CD44 and CD54 were expressed in 58.4 and 31.72% of cases, respectively. CD54 expression showed a direct correlation with the degree of histological anaplasia and Ki67 values. More than half of cases (58.11%) were negative for E-cadherin, mostly the anaplastic ones, which also showed less positive areas for this marker. Cell adhesion molecules were not significantly related to a particular histological type and proliferating potential of meningiomas. Overall, CD54 as well as E-cadherin could be used as additional aggressiveness indicators aside the classical ones. On the other way, Ki67 once again confirmed its significant role in the assessment of meningioma aggressiveness.

Corresponding author: Dorel Arsene, MD, PhD; e-mail: dorelarsene@yahoo.com

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12. Electron microscopy analysis of different orthodontic brackets and their adhesion to the tooth enamel

Delia Ioana Ciocan, Dragos Stanciu, Manuela Anca Popescu, Florin Miculescu, Ioan Plotog, Gaudentiu Varzaru, Lucian Toma Ciocan

This study proposed to evaluate the surface morphology of different types of orthodontic brackets and the characteristics of their adhesion to the tooth enamel. There have been taken into study six metallic, five ceramic and one polymeric bracket from different brands (Ormco, Lancer, Leone, Damon, 3M, Ultradent, American Orthodontics, Rocky Mountain). The surface base of the each bracket it have been ESEM analyzed using scanning electron microscope Phillips XL-30 ESEM. There have been investigated several parameters that have a potential influence of the bracket-bonding agent interface joint: chemical composition, roughness, surface morphology and wideness. After ESEM analysis, the same metallic and ceramic brackets have been afterwards collated on extracted teeth and subjected to mechanical tests. After the mechanical testing, the samples were once again ESEM investigated. All fractures occurred in the area of the adhesive system, recording adhesive fractures of the tooth-composite resin and composite-bracket, cohesive fractures and both. The metallic brackets surfaces that are optima for a good adhesion is that of a mesh sand blasted and acid etched. From the esthetic brackets, the ceramic ones are superior to polymeric ones regarding bonding to teeth.

Corresponding author: Delia Ioana Ciocan, Assistant Professor; e-mail: delia_ciocanaru@yahoo.com

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13. Technological update of the video-endoscopic approach of the diagnosis and staging of tumors in children

Isabela-Magdalena Draghici, Dragos-Constantin Luca, Maria-Delia Popescu, Liviu Draghici

The pediatric patient is often difficult to diagnose, especially since the surgical pathology is tumoral. Establishing the histopathological diagnosis of a tumor, staging of a disease and certifying the existence of rare pediatric affections are three of the motives for which the specialists frequently appeal to an exploratory laparoscopy, accompanied by biopsy procedures. The paper presents the laparoscopic biopsy experience of the team from the Department of Pediatric Surgery, Maria Sklodowska Curie Emergency Clinical Hospital for Children, Bucharest, Romania. From 2000 to 2013, 95 such procedures were performed (7.76% of a total of 1224 laparoscopic interventions). In many cases, the laparoscopy had an exclusive diagnostic purpose, of whose success has been primarily responsible the targeted biopsy. Current issues are discussed, centered on the most advanced technologies used in minimally invasive approach of pediatric malignancies, referring to the effect of minimizing the possible complications that can arise from this type of intervention. The authors concluded that laparoscopic technique is the method of choice in comparison to other ways of biopsy (classical surgery, ultrasound guidance, tomography, etc.), and it is characterized by a high diagnostic value.

Corresponding author: Isabela-Magdalena Draghici, Lecturer, MD, PhD; e-mail: isabelamagdalena@yahoo.com

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14. Tonsillar hypertrophy implications in sleep disorders in adults and children

Reka Solyom, Iren Csiszer, Adriana Neagos

Introduction: The obstructive sleep apnea syndrome is the most common sleep disorder. It covers a multitude of symptoms associated with apnea. Next to polysomnography, otorhinolaryngological clinical examination plays an important role in establishing the diagnosis, in evaluating any oropharyngeal and hypopharyngeal modification. Patients and Methods: In this research, we intend to demonstrate the histopathological examination importance in establishing the tonsillar hypertrophy degree. This is made in direct correlation with its volume, and the sleep apnea degree. In this context, we have conducted a retrospective study between 2007-2012 on a group of 69 patients diagnosed by polysomnography with Obstructive Sleep Apnea (OSA). In the research, otorhinolaryngological examination was supplemented with histopathological examination of the parts collected after the surgery. Results: It has been demonstrated that the size, volume of the tonsil can be directly correlated with the severity of sleep apnea. The term tonsil hypertrophy is a histopathological one, with or without macroscopic implications. A specificity of tonsil enlargement without the narrowing of the oropharyngeal isthmus was demonstrated. This was in all groups of obstructive apnea, even in snoring patients with normal apnea-hypopnea index values, with a non-significant statistical correlation. Conclusions: The use of multiple indices in the classification of OSA severity is an important advantage. Therefore, it can be proved that there is no singular structure to induce the disorder, but the cause is rather a combination of several elements. The polysomnographic examination remains the golden standard for assessing in patients with OSA.

Corresponding author: Adriana Neagos, Senior Lecturer, MD, PhD; e-mail: neagos.adriana@gmail.com, adriana.neagos@galenus.ro

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15. Experimental morphologic and radiologic study of the integration of bone grafts into the host tissue and of the dynamics of the graft-receptor interface

Horatiu Pompiliu Petrescu, Gabriel Dinu, Gheorghe Noditi, Marcel Berceanu-Vaduva, Dana Cristina Bratu, Dinu Vermesan

Bone is the second tissue in terms of number of transplants after blood. There is an increased trend of incidence of severe bone lesions with comminuted fractures, with significant lack of substance, as well as an increased incidence of cancer types combined with therapeutic advances in recent decades, allowing for large surgical interventions that affect the bones and create significant defects in bone and contribute to the overall increase in the number and complexity of bone transplants. Autografts may be used singly or in various combinations, with significantly better effects than other implant materials. Use of autografts is limited by complications from the receptor site, mainly related to infections and undetectable necrotic areas on initial microscopic examination, which prevent proper incorporation of autografts, but also those of the donor situs. The aim of the study was to assess the integration of tibial bone grafts into the femur of Wistar rats by radiologic exam and histological evaluation. We concluded that the fixing of the graft to the host tissue may be subject to some microenvironment influences. The presence of the periosteum on the grafts is certainly an asset during transplantation. We confirm once again that the ability of transplanted periosteum of osteoformation and reactivation. Our observations regarding the contribution of bone marrow endorse the view of its active role in bone formation.

Corresponding author: Horatiu Pompiliu Petrescu, Assistant Professor, MD, PhD; e-mail: lalusha87@yahoo.com

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16. The macroscopic examination of the placental vasculature with a corrosive agent

Izabella Petre, Roxana Folescu, Onut Bacean, Anca Bordianu, Ioana Mihaela Luca, Elena Bernad, Marius Lucian Craina

The placental development is a complex process, in which any disturbance can induce changes with grave consequences for the offspring. Villi and villous vascularization development is in, and underdevelopment can lead to villous placental insufficiency. This paper aims to analyze the arterial and venous vasculature of the placenta, both macroscopic and morphologically, by different injection techniques of contrast agents (plastic substances type AGO II) in 50 human placentas with different ages of gestation.

Corresponding author: Elena Bernad, Assistant Professor, MD, PhD; e-mail: ebernad@yahoo.com

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17. A histopathological and immunohistochemical approach of surgical emergencies of GIST. An interdisciplinary study

Vlad Denis Constantin, Bogdan Socea, Florian Popa, Alexandru Constantin Carap, Gheorghe Popescu, Teodora Vladescu, Zenaida Ceausu, Serban Vifor Gabriel Bertesteanu, Mihail Constantin Ceausu

The tailored approach to gastrointestinal stromal tumors (GISTs) has led to better prognosis for these types of tumors. Also, finding out GIST s pathology has led to a better understanding of oncogenesis and cancer therapy in general. The rapid expansion of molecular and pathological knowledge of GISTs has given this disease a promising future. We analyze 30 cases of GISTs operated on in our clinic with confirmed diagnosis by immunohistochemistry. Most of the cases were acute cases that required urgent surgical therapy. An extended analysis of these cases is performed in order to underline their special features. We recorded 17 GISTs of the stomach, 12 GISTs of the small bowel and one esophageal GIST. Of the 30 cases, 15 cases required urgent surgery presenting with GI bleeding or shock following intraperitoneal rupture and bleeding or intestinal obstruction. Of the 15 cases that required urgent surgery 12 cases presented with serosal involvement. Twenty-four cases presented spindle cell histology, four cases were epithelioid and two cases presented mixed cellularity. Although acute presentation of GISTs is not the rule, 15 of 30 of our cases required immediate surgery and a high proportion of them (12/15) presented with serosal involvement. Serosal involvement may warrant the need for a macroscopic classification of GISTs and correlation to therapy. While overall mortality was not high in our series, morbidity is affected by acute presentation, though not specifically pertaining to the diagnosis of GIST. Acute presentations were more frequent, in our series, for small bowel GISTs, compared to gastric GISTs. Serosal involvement was more frequent in the group with acute presentation compared with non-acute GISTs and was present at the most cases of small bowel GISTs with acute onset. The Ki-67 index showed no difference between acute and non-acute onset of GISTs.

Corresponding author: Bogdan Socea, Assistant Professor, MD; e-mail: bogdansocea@gmail.com

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18. Immunohistochemical and molecular features of primary clear cell-adenocarcinoma of the rectum, as predictive factors for individualized therapy

Simona Gurzu, Ioan Jung, Tivadar Bara, Tivadar Bara Jr., Orsolya Serester

An 82-year-old male was hospitalized with rectal carcinoma that was confirmed endoscopically. Surgical resection of the rectum was performed. Intraoperative examination showed a solitary hepatic metastasis; metastasectomy was also performed. Histological examination of the surgical specimen showed mainly a trabecular arrangement of the tumor cells, alternating with tubuloglandular areas, the tumor being diagnosed in stage IV. The high-power-view examination showed that the tumor cells presented clear cytoplasm, and were diffusely marked by AE1/AE3 keratin, carcinoembryonic antigen (CEA), and CD10. A focal immunostain was also observed for keratins 7/20, vascular endothelial growth factor (VEGF), and its receptor (VEGF-R2). The tumor was proved to be microsatellite stable, presenting K-ras mutation. Based on the immunoprofile and computer scanning, metastases from clear cell renal cell carcinoma and adrenocortical carcinoma have been excluded. Based on these characteristics and the tumor stage, the final diagnosis was primary clear cell adenocarcinoma (CCA). Bevacizumab-based antiangiogenic therapy was indicated. This is the 12th primary CCA of the colorectum ever reported, and the first from Eastern Europe.

Corresponding author: Ioan Jung, Professor, MD, PhD; e-mail: jungjanos@studium.ro, simonagurzu@yahoo.com

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19. Completely regressed primary cutaneous melanoma - difficulties in diagnosis and classification

Irina Margaritescu, Aurel Doru Chirita, Florina Vasilescu

Complete regression of primary cutaneous melanoma is a very rare phenomenon. Only 49 cases of well-documented completely regressed primary cutaneous melanoma have been reported to date. The clinical picture and histological findings may vary considerably. The presence of regional lymphadenopathy represents a necessary requisite for the diagnosis of completely regressed primary cutaneous melanoma. However, some cases lie outside these criteria and are difficult to diagnose and classify. Moreover, completely regressed melanoma is not specifically referred to in the current AJCC (American Joint Commission on Cancer) melanoma staging system. We report three cases of completely regressed primary cutaneous melanoma. One of the cases presented with unquestionable clinical and histopathological findings of completely regressed primary cutaneous melanoma, but without concomitant regional lymph node metastasis. As expected, this patient eventually developed nodal metastatic disease. An extraordinary case of a completely regressed melanoma that appeared in association with a congenital melanocytic nevus is also documented. This case revealed a unique type of regression that affected only the melanoma. The nevus was left undisturbed by the immunological response.

Corresponding author: Irina Margaritescu, MD, DipRCPath; e-mail: irina.margaritescu@gmail.com

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20. Collision tumor of recto-sigmoidian junction - case presentation

Cristian Mesina, Ion Vasile, Daniela Ciobanu, Firmilian Calota, Corina Lavinia Gruia, Liliana Streba, Stelian Stefanita Mogoanta, Horia Parvanescu, Claudia Valentina Georgescu, Danut Nicolae Tarnita

Collision tumors of the colon are rare. A 64-year-old man was referred on Emergency County Hospital, Craiova, Romania for the evaluation of intestinal obstruction. Colonoscopy demonstrates the presence of about 9/5 cm sized mass in the rectosigmoid junction. After surgical resection, the rectosigmoid lesion was histopathologically composed of two distinct lesions: mucoid adenocarcinoma in the superficial layer and poorly differentiated neuroendocrin carcinoma in the deeper layer. A rectosigmoid tumor showed two distinct tumors with no admixture or transposition of two neoplastic components. A lymph node metastatic deposit contained both tumors. Immunohistochemical stainings were consistent with mucinous adenocarcinoma and neuroendocrine carcinoma of the two neoplasms. We report this case of colonic collision tumor (mucoid adenocarcinoma and neuroendocrine carcinoma) and review of the literature.

Corresponding author: Daniela Ciobanu, Lecturer, MD, PhD; e-mail: elada192@yahoo.com

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21. Histopathological findings concerning ocular melanomas

Mariana Costache, Oana Maria Patrascu, Adrian Dumitru, Diana Costache, Liliana Mary Voinea, Olga Simionescu, Maria Sajin

Ocular melanoma is rare in clinical practice. In this study, we present three cases of ocular melanoma surgically removed in the Department of Ophthalmology of the Emergency University Hospital of Bucharest, Romania, and diagnosed in the Department of Pathology of the same hospital using conventional histopathological techniques and immunohistochemical tests._x000D_

Corresponding author: Mariana Costache, Associate Professor, MD, PhD; e-mail: m_costache_dermatopat@yahoo.com

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22. Cherubism: a case report

Octavian Dinca, Emilia Severin, Cristian Vladan, Dana Cristina Bodnar, Alexandru Bucur

Cherubism is a familial benign fibro-osseous disease of the jaws. On radiography, the lesions exhibit bilateral multinuclear radiolucent areas. Histopathology reveals multinucleated giant cells in the background of proliferating fibrous connective tissue. Mutations in the SH3BP2 gene are identified as the cause of cherubism. A 12-year-old girl with prominence of the lower face was investigated. Her chief complaint was her facial appearance with asymmetrical swelling of the cheeks. Clinical and radiographic examinations, and biopsy, biochemical analysis and genetic investigations were performed.

Corresponding author: Emilia Severin, MD; e-mail: genetics.dentistry@gmail.com

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23. Relevant infrastructural alterations in a pancreatic neuroendocrine tumor: an insulinoma case

Gabriel-Valeriu Mirancea, Ana-Maria Morosanu, Simona Carniciu, Simona Dima, Nicolae Bacalbasa, Irinel Popescu, Constantin Ionescu-Tirgoviste, Nicolae Mirancea

In this study, we focus our interest on some peculiar infrastructural abnormalities detected in an insulinoma case. Tumor pancreatic endocrine cells proliferated detrimental to exocrine counterpart, so that extensive areas of prevalent beta-tumor cells can be seen. Two phenotypes of beta-tumor cells can be identified: (1) beta-tumor cells with full euchromatic and nucleolated nuclei and (2) beta-tumor cells with heterochromatic and shrink nuclei. Because of stroma alteration, including basement membrane, cell-extracellular matrix junctions are also compromised. The mostly striking and important finding in this report for a case of insulinoma is the high fragility of plasma membrane of both two phenotypes of beta-tumor cells. Cell-cell junctions, especially desmosomal junctions are severely altered, almost missing, plasma membranes showed shedding membrane vesicles and extensive dissolutions leading to pseudo-syncytia formation. Extravasated blood cells, including inflammatory cells contribute to the dramatic and extensive destructive areas of epithelial cells as well as stroma counterpart. Moreover, also the inner cell cytomembranes exhibit abnormalities: many beta-tumor cells have excessive dilatations of nuclear envelope and endoplasmic reticulum. All above severe infrastructural abnormalities, especially down regulation of cell-cell and cell-extracellular matrix adhesions and plasma membranes fragility might result in aberrant cell behavior and, consequently, much care should be taken for the postoperatory patient evolution.

Corresponding author: Nicolae Mirancea, Professor, PhD; e-mail: nick_mirancea@yahoo.com

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24. Clinicopathologic and therapeutic aspects of giant parathyroid adenomas - three case reports and short review of the literature

Radu Mircea Neagoe, Daniela Tatiana Sala, Angela Borda, Carmen Aurelia Mogoanta, Gheorghe Muhlfay

In the last decade, the clinical picture of primary hyperparathyroidism has changed, with the majority of patients being diagnosed while asymptomatic and the classical clinical pattern characterized by bone disease, recurrent nephrolithiasis, peptic ulcer disease, neurological or psychiatric disorders being rarely encountered. In this context, most patients have minimal hypercalcemia and small parathyroid adenomas. Not surprisingly, giant parathyroid adenomas have seldom been described in the literature. We herein report three cases of giant parathyroid adenomas weighing more than 30 g and discuss their clinicopathological and therapeutic particularities. We also review the relevant literature, with the principal aim of outlining the rarity of these giant parathyroid adenomas and the issues concerning their diagnosis and treatment.

Corresponding author: Daniela Tatiana Sala, MD; e-mail: salatatiana78@gmail.com

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25. Fronto-parietal pial extension of a basal cell carcinoma of the scalp - case report

Ionica Pirici, Otilia Margaritescu, Daniela Cernea, Loredana Elena Stoica, Calin-Gabriel Sarla, Daniel Pirici

Basal cell carcinoma is the most common malignant tumor of the skin, and it develops most frequently on the head and neck regions. Although most of these tumors are slow growing and with a limited evolution, the existence of some aggressive variants accompanied by a complete neglect from the patient may occasionally lead to invasion of the face and organs of the head and neck. Even though, intracranial invasion of basal cell carcinoma of the scalp is a rare presentation. We describe here the case of a woman who developed an aggressive and neglected morpheiform basal cell carcinoma (ulcus terebrans), which showed a complete invasion through the skull, but with an apparent self-limitation to the pia mater._x000D_

Corresponding author: Daniel Pirici, Lecturer, MD, PhD; e-mail: daniel.pirici@yahoo.com

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26. Unusual lesion of the temporal region, benign tumor of the Chievitz s organ: a case report

Serban Rosu, Carmen Neamtu, Bogdan Totolici

Normally present in the temporal region, the juxtaoral organ of Chievitz has considerable importance for both the surgeon and the pathologist. Although very rare, the nodular hyperplasia of the Chievitz s organ has been misinterpreted as invasive carcinoma. The pathological aspect mimics the mucoepidermoid carcinoma, squamous carcinoma, basal cell carcinoma with sebaceous differentiation or tumor of the skin appendages. We present the case of a 71-year-old patient admitted with temporal tumor. The initial pathological diagnosis was mixed squamous basal cell carcinoma. The subsequent evaluation of sections and immunohistochemistry allowed us to demonstrate a benign tumor of the Chievitz s organ. In this case, therapy and prognosis are strongly related to the correct diagnosis and avoid an over treatment of a benign tumor._x000D_

Corresponding author: Serban Rosu, University Assistant, MD, PhD; e-mail: serbanrosu@yahoo.com

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27. Trichilemmal carcinoma - a rare cutaneous malignancy: report of two cases

Maria Sajin, Mihaela Cristina Luchian, Alina Hodorogea Prisacaru, Adrian Dumitru, Oana Maria Patrascu, Diana Costache, Doina Dumitrescu, Ana Maria Oproiu, Olga Simionescu, Mariana Costache

The trichilemmal carcinoma is a rare low-grade malignant lesion originating from hair follicle cells that usually occurs on sun-exposed skin of older individuals. A differential diagnostic is required with other skin carcinomas. We report two cases of trichilemmal carcinoma admitted at the Emergency University Hospital of Bucharest, Romania, in 2012, one of these cases being localized in the periocular area and the other one resembling a cutaneous horn. These cases present several unusual aspects that are rarely described in the literature namely the site of the tumor which in the eyelid, development of a cutaneous horn, IHC tests which revealed EMA (epithelial membrane antigen) positivity in tumor cells. Considering that this type of tumor seldom develops metastases or local recurrences, and all the cases had free margins, there was no adjuvant therapy.

Corresponding author: Mariana Costache, Associate Professor, MD, PhD; e-mail: m_costache_dermatopat@yahoo.com

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28. Implant overdenture and Locator system in edentulous patient with severely resorbed mandible - a case report

Camelia Ionescu, Bogdan Mihai Galbinasu, Horia Manolea, Ion Patrascu

Clinical studies have revealed that the main objective of implants in the edentulous jaw is to provide support for fixed prostheses or to stabilize complete dentures. Various attachment systems were developed for universal use in partially and completely edentulous patients such as clasps, cone-shape telescope copings, magnets, bar systems, locators. The aim of this case report is to present the Locator attachment that does not use the splinting of implants. Four implants were placed in the foraminal region and the Locator attachment system was used to connect overdentures to mandibular dental implants. The results proved that the Locator attachment system offers the possibility to obtain a higher retention and an improved stability for overdentures in edentulous patients with a severely resorbed mandible and lack of vertical space between the arches.

Corresponding author: Bogdan Mihai Galbinasu, Assistant, MD, PhD; e-mail: bogdan.galbinasu@yahoo.com

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29. Primary ciliary dyskinesia diagnosed by electron microscopy in one case of Kartagener syndrome

Aniela-Luminita Rugina, Alexandru Grigore Dimitriu, Nicolai Nistor, Doina Mihaila

Primary ciliary dyskinesia (PCD) is associated with abnormalities in the structure of a function of motile cilia, causing impairment of muco-ciliary clearence, with bacterial overinfection of the upper and lower respiratory tract (chronic oto-sino-pulmonary disease), heterotaxia (situs abnormalities), with/without congenital heart disease, abnormal sperm motility with male infertility, higher frequency of ectopic pregnancy and female subfertility. The presence of recurrent respiratory tract infections in the pediatric age requires differentiation between primary immunodeficiency, diseases with abnormal mucus (e.g., cystic fibrosis) and abnormal ciliary diseases. This case was hospitalized for recurrent respiratory tract infections and total situs inversus at the age of five years, which has enabled the diagnosis of Kartagener syndrome. The PCD confirmation was performed by electron microscopy examination of nasal mucosa cells through which were confirmed dynein arms abnormalities. The diagnosis and early treatment of childhood PCD allows a positive development and a good prognosis, thus improving the quality of life.

Corresponding author: Aniela Luminita Rugina, MD, PhD; e-mail: aniela_virlan@yahoo.com

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30. Histological patterns in orbital malignant tumors

Viorel Ibric-Cioranu, Vasile Nicolae, Daniel Iorgulescu, Iulian Mihai Fagetan, Vlad Petrescu Seceleanu, Mihaela Cernusca-Mitariu, Silviu Nicolae, Sorin Ibric-Cioranu

There is a wide variety of tumors affecting the orbit. The most encountered histological type of malignant orbital tumor is the basal cell carcinoma followed by the malignant melanoma and the squamous cell carcinoma. The authors conducted a retrospective review of the malignant orbit tumors from the Department of Oral and Maxillofacial Surgery, University Emergency Hospital of Sibiu, Romania. The main surgical methods implied were tumor resection, exenteration and extended exenteration. The reconstruction was performed with the help of local flaps using different techniques: advancement, translation or rotation. The use of local flaps allowed for a good esthetic outcome and a decrease in the healing time.

Corresponding author: Viorel Ibric-Cioranu, Professor, DMD, PhD; e-mail: maxfaxsurg@yahoo.com

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31. Ectopic jejunal pancreas and congenital duodenal stenosis in a newborn patient: an unusual association

Laura Mihaela Trandafir, Sandu Gabriel Aprodu, Doina Mihaila, Dana Teodora Anton Paduraru, Lacramioara Butnariu, Iulia Carmen Straticiuc Ciongradi

Congenital duodenal stenosis is one of the most common causes of neonatal obstruction, which is frequently associated with annular pancreas and Down syndrome. Ectopic pancreas is defined as an abnormally situated pancreatic mass that lacks contact with normal pancreas. Although the association between duodenal stenosis and annular pancreas is very common, the presence of an ectopic island of pancreas in such cases is very rare. We present a case of unusual association of duodenal stenosis, jejunal ectopic pancreas in a neonate with Down syndrome.

Corresponding author: Sandu Gabriel Aprodu, Assistant Professor, MD, PhD; e-mail: drpediatrie@yahoo.com

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32. A rare case of osteoma in the frontal sinus: anatomical and histological description

Cristian Funieru, Bogdan Banica, Cristian-Niky Cumpata, Ruxandra Ionela Sfeatcu, Adina Mihaela Dumitrache, Mihaela Raescu, Ionela Teodora Dascalu, George Simion, Mihaela Jana Tuculina

Purpose: The purpose of this paper is to present a rare case of osteoma localized in the left frontal sinus. A 22-year-old woman who arrived at the Department of Neurosurgery of the University Emergency Hospital, Bucharest, Romania, presented a vertical asymmetry of the eyeballs but displayed no clinical signs like pain or diplopia. The computer tomography exam was used for preoperatory diagnostic. Histopathology was performed after surgery using Hematoxylin and Eosin staining. The Nikon Eclipse microscope was used to examine the slides. Results: The histopathology exam shows a compact osteoma with dense and non-Haversian bone tissue and parallel bony trabeculae. A few spaces for the marrow were also found. The osteocytes were small and no fibrous cells were discovered. Conclusions: The computer tomography and histopathology exam were the investigations that lead us to a true diagnostic of dense osteoma. This tumor was the first case of frontal sinus osteoma histologically described in the Romanian population.

Corresponding author: Mihaela Raescu, Associate Professor, DMD, PhD; e-mail: mihaela.raescu@gmail.com

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33. Extensor digitorum brevis manus with X tendons

Qing-hua Mao, Jing Li

During the educational dissection of a 72-year-old Chinese male cadaver, bilateral extensor digitorum brevis manus (EDBM) muscles were observed. The left EDBM muscle originated from the joint capsule ligament, running across the second dorsal interosseous muscle as double tendons (EDBM ulnar tendon and EDBM radial tendon) on the ulnar side of extensor digitorum communis (EDC)-index finger. The EDBM radial tendon positioned ventrally but inserted further to the ulnar tendon so that they made an X shape. The right EDBM muscle arose from dorsal radiocarpal ligament, coursing the second dorsal interosseous muscle and inserted into the ulnar side of EDC-index finger.

Corresponding author: Qing-hua Mao, Resident; e-mail: maoqinghua629@yahoo.com

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34. Biomedical research - opportunities and ethical challenges

Liliana Rogozea, Daniel Purcaru, Florin Leasu, Codruta Nemet

Purpose: The principal purpose of this paper is to analyze the main opportunities and challenges in biomedical research, thus contributing to improving compliance with ethical norms within the context of continuously expanding research, such as to ensure better quality of patient care and reduce the risk of research not observing the totality of patient rights. Background: Since antiquity finding ways to give care to people has represented not only an opportunity, but also a challenge materialized in experimenting and self-experimenting - a constant part of caregivers activity. Medical research, whether fundamental or applied, is not only essential to evolution in medicine, but also the way towards increasing the quality of individual lives. Content: The article undertakes to analyze the main ethical norms governing medical research, starting from historical experience and literature search. Discussion: The growing number of people engaged in medical research over the last years has turned bioethics into an increasingly applicative science, capable of developing practical standards to ensure the moral advancement of the medical profession. Conclusions: The bioethics of the last years has been more and more tied to the reality of medical practice, as well as to that of scientific research, contributing increasingly to the integration of moral elements into medical activity and to the development of research in interdisciplinary bioethics. Bioethics and more so bioethical education need to be correlated with the transition from research itself for the purpose of publishing and career advancement to research based on altruism and the desire to contribute to the wellbeing of patients.

Corresponding author: Florin Leasu, University Assistant, MD, PhD student; e-mail: florinleasu@yahoo.com

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35. Letter to the Editor. Skin telopodes

Mugurel Constantin Rusu

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Corresponding author: Mugurel Constantin Rusu, Associate Professor, MD, PhD, Dr. Hab.; e-mail: anatomon@gmail.com

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