ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 56 No. 2, 2015

1. The nucleocrine pathway comes of age

Razvan T. Radulescu

More than 20 years ago, it was initially predicted that hormones and growth factors might promote cell growth by binding and thereby inactivating tumor suppressors, as exemplified by the proposed complex formation between insulin and retinoblastoma protein (RB). This mainly intracellular/nuclear growth-regulatory circuit was termed the nucleocrine pathway and the physical interaction between insulin and RB was subsequently proven through several methods, primarily by immunofluorescence and co-immunoprecipitation. Meanwhile, additional nucleocrine pairs have emerged through further experimental studies, specifically the FGF1-p53 and angiogenin-p53 heterodimers. Moreover, first experimental clues have been obtained as to the intranuclear presence of the previously surmised heterodimer between the EGF precursor and the p130 tumor suppressor. In addition, RB-binding motifs have recently been discovered in interleukin-6 (IL-6) and cellular apoptosis susceptibility (CAS) protein. These findings point to a more general significance of the nucleocrine pathway in cell growth regulation and as a particularly useful target in cancer therapy.

Corresponding author: Razvan Tudor Radulescu, MD, PD Dr. med.; e-mail: ratura@gmx.net

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2. Carbon nanotubes for cancer therapy and neurodegenerative diseases

Elena Daniela Melita, Gabriela Purcel, Alexandru Mihai Grumezescu

Our review summarizes the latest approaches regarding a new class of nanomaterials - carbon nanotubes (CNTs) -, which are promising candidates in different areas of nanomedicine. This paper discusses the main applications of CNTs in the repair of injured nerves and also as delivery systems for cancer therapy in difficult to reach anatomic sites. In terms of neurological applications, we focus on neural interface, neural stimulation, microelectrodes, and differentiation of stem cell into neural cells. Also, we highlight the in vitro and in vivo applications of CNTs-mediated cancer therapy and we will explain why CNTs are used for the treatment of difficult tumors.

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

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3. Prognostic significance of MMP-9 and TIMP-1 in liver metastases

Simona Eliza Giusca, Irina-Draga Caruntu, Cornelia Amalinei, Elena-Roxana Avadanei

Our research focuses both on the correlations between MMP-9 and TIMP-1 and classical clinicopathological factors and on the prognostic value of MMP-9 and TIMP-1 for survival. The study group included 52 patients diagnosed with hepatic metastases. The tissue specimens have been specifically processed for immunohistochemical exam, by using anti-MMP-9 and anti-TIMP-1 antibodies. For the semi-quantitative assessment, we have used an individualized score, which values allowed the discrimination of two classes of cases (low and high), using two different thresholds: <=4 and <4. Data have been statistically analyzed by using Fisher 2x2 test and Kaplan-Meier curves. Statistical analysis between MMP-9 and TIMP-1 expression (low versus high, separately for each threshold) and clinicopathological characteristics had not revealed significant differences. In both types of threshold applied in survival analysis, significant differences between MMP-9 and TIMP-1 low and high expression have been demonstrated. For cases with concordant MMP-9-TIMP1 co-expression, low versus high, the survival analysis revealed that threshold value <4 offers a better stratification of cases when compared to threshold value <=4, based on significant differences registered only for threshold value <4. No significant differences were registered between cases with discordant MMP-9-TIMP-1 co-expression, for both thresholds. Regardless of the used threshold, the survival analysis achieved between the cases with MMP-9-TIMP-1 concordant co-expression and cases with MMP-9-TIMP-1 discordant co-expression had proven significant differences. Our study suggests that the confirmation of MMP-9 and TIMP-1 value as prognostic factors, based on immunohistochemical expression, requires a threshold validation.

Corresponding author: Irina-Draga Caruntu, Professor, MD, PhD; e-mail: irinadragacaruntu@gmail.com

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4. Biocompatible hydrodispersible magnetite nanoparticles used as antibiotic drug carriers

Alexandra Bolocan, Dan Eduard Mihaiescu, Ecaterina Andronescu, Georgeta Voicu, Alexandru Mihai Grumezescu, Anton Ficai, Bogdan Stefan Vasile, Coralia Bleotu, Mariana Carmen Chifiriuc, Corina Silvia Pop

Here we report a newly synthesized vectorizing nanosystem, based on hydrodispersible magnetite nanoparticles (HMNPs) with an average size less than 10 nm, obtained by precipitation of Fe(II) and Fe(III) in basic solution of p-aminobenzoic acid (PABA), characterized by high-resolution transmission electron microscopy (HR-TEM), dynamic light scattering (DLS), X-ray diffraction (XRD), differential thermal analysis coupled with thermogravimetric analysis (DTA-TGA) and bioevaluated for cytotoxicity and antibiotic delivery in active forms. The obtained data demonstrate that HMNPs can be used as an efficient drug delivery system, for clinically relevant antimicrobial drugs. HMNPs antimicrobial activity depended on the loaded drug structure and the tested microbial strain, being more efficient against Pseudomonas aeruginosa, comparing with the Escherichia coli strain. The novel HMNPs demonstrated an acceptable biocompatibility level, being thus a very good candidate for biomedical applications, such as drug delivery or targeting.

Corresponding author: Dan Eduard Mihaiescu, Chem. Eng., PhD; e-mail: danedmih@gmail.com

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5. Ultrastructure of the human palatine tonsil and its functional significance

Marko Jovic, Verica Avramovic, Predrag Vlahovic, Vojin Savic, Aleksandra Velickov, Vladimir Petrovic

The human palatine tonsils represent a mucosa-associated lymphoid tissue with a significant function in mucosal protection against alimentary and airborne pathogens. The ultrastructure of different morphological compartments in the human palatine tonsil was studied in eighteen tonsils obtained from the patients who had undergone elective tonsillectomy due to chronic tonsillitis. The tonsillar specimens were analyzed by scanning and transmission electron microscopy. The results showed the presence of tight junctions between superficial epithelial cells of the oropharyngeal tonsillar surface. The crypt epithelium is a sponge-like structure infiltrated by non-epithelial cells, mostly lymphocytes, and is characterized by the presence of small pores - microcrypts occupied by large microvillus cells and/or lymphocytes. Antigen-presenting Langerhans cells with typical intracytoplasmic Birbeck granules were also found in the crypt epithelium. The lymphoid follicles are composed of lymphocytes and two types of non-lymphoid follicular cells: small fibroblast-like cells and large cells, morphologically consistent with antigen-bearing follicular dendritic cells or macrophages. The interfollicular areas consisted of a dense network of reticular cells and reticular fibers; many lymphocytes were interspersed between the reticular fibers. In addition to arterioles and high endothelial venules in the interfollicular lymphoid tissue, some fenestrated capillaries were seen intraepithelially and subepithelially. The complex ultrastructure of the human palatine tonsil provides a microenvironment necessary for antigen uptake, antigen processing and immune response.

Corresponding author: Marko Jovic; e-mail: marko.jovic@medfak.ni.ac.rs

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6. BRCA1 5382insC founder mutation has not a significative recurrent presence in Northeastern Romanian cancer patients

Lucian Negura, Cristian Petru Dusa, Miruna Ioana Balmus, Doina Azoicai, Anca Mihaela Negura, Mihai Vasile Marinca, Lucian Miron

Developed two decades ago, oncogenetic medical practice mainly concern breast, ovarian and colorectal cancers, and is targeting the hereditary risk factor, the only one that shows positive predictive value justifying the molecular diagnosis. Screening for BRCA1 and BRCA2 gene mutations is standard practice today for hereditary breast and ovarian cancer (HBOC) families in developed countries, offering the possibility of medical follow-up. The gold standard for molecular diagnosis is Sanger sequencing of all exons and exon-intron boundaries, which is expensive and time consuming. More than 3000 BRCA sequence variants are reported in international databases, but in some populations or ethnic groups a few founder mutations showed to have a recurrent presence. This may be very useful in establishing a combined technical approach for mutation detection, including rapid and cheap pre-screening methods for most common mutations. The BRCA1 5382insC mutation has an Ashkenazi founder effect and is also the second most recurrent mutation in Eastern European populations, having been already identified in several Romanian HBOC patients. Here we present a complete screening of consecutive series of breast and ovarian cancer patients for the presence of BRCA1 5382insC. The presence of the mutation was investigated by allele specific multiplex-PCR on genomic DNA extracted from peripheral blood. No mutation carrier was identified among breast or ovarian cancer patients. Our findings suggest that BRCA1 5382insC may not have a strong recurrent effect in Romanian population comparing to neighboring countries. This may be particularly useful in establishing further pre-screening strategies.

Corresponding author: Lucian Negura, Lecturer, PhD; e-mail: luciannegura@yahoo.fr

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7. Paraoxonase 1 genotype-phenotype correlation in patients with metabolic syndrome

Lorena Ciumarnean, Eleonora Dronca, Stefan Cristian Vesa, Dorel Sampelean, Anca Dana Buzoianu, Andrei Achimas-Cadariu

The aim of the study was to investigate the influence of three single nucleotide polymorphisms (SNPs) (-108C>T, -162A>G and -909G>C) from the promoter region of paraoxonase 1 (PON1) gene on the enzyme activity, in patients with metabolic syndrome (MS). The study group consisted of 61 individuals with MS and the control group of 73 individuals without MS, matched for age and gender. For each individual, clinical and genetic parameters with possible influence on PON1 activities (paraoxonase, arylesterase and lactonase) were measured. PON1 genotyping was performed with PCR-RFLP, using specific primers and restriction enzymes. We found no differences for distribution of PON1 -108C>T, -162A>G and -909G>C polymorphisms, between the two groups (p-NS). The -108C>T and -909G>C polymorphisms were associated with paraoxonase (p=0.03, p=0.006, respectively), arylesterase (p<0.001, p<0.001, respectively) and lactonase (p<0.001, p<0.001, respectively) activities. The -162A>G polymorphism was not associated with paraoxonase (p-NS) or lactonase (p-NS) activities, but influenced the arylesterase activity (p=0.03). PON1 activities were influenced by all three polymorphisms, regardless of the presence of MS.

Corresponding author: Stefan Cristian Vesa, Assistant Lecturer, MD, PhD; e-mail: stefanvesa@gmail.com

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8. Sonographic evaluation of fetal cerebral structures correlated with histological aspects

Alexandru Cristian Comanescu, Nicolae Cernea, Oana-Sorina Tica, Maria Victoria Comanescu, Elena Carmen Niculescu, Charoula Florou, Florin Grosu

Prenatal development of the human brain from undifferentiated neuroepithelium, crosses numerous steps towards primordial organization and subsequent cytoarchitectural layering, ascending and progressive from the lower cortical layers to the superior ones. Our study represents a systematic, comparative assessment of imaging studies and the histological evaluation of the prenatal development of the human brain. We evaluated 232 cases using 3D ultrasound. Histological study was performed on 17 cases aged between 8 and 32 weeks pregnancy and compared with imaging results. For the ultrasound study, we chose five anatomical landmarks: the choroid plexus, thalamus, cerebellum, hippocampus and island (Sylvian fissure). The histological study was performed on dissected brain specimens preserved in formaldehyde and was followed by immunohistochemical determination in order to complete the picture of the morphological evolution of the structures evaluated. We analyzed the accuracy of the description of marker elements (choroid plexus, thalamus, cerebellum, hippocampus and Sylvian fissure) in three-dimensional ultrasound evaluation. This showed a good correlation with the morphological evaluation as well as with the dimensional descriptions from the literature. Histological and immunohistochemical assessment helped complete the picture of the central nervous system development. Highlighting fetal cerebral structures by three-dimensional ultrasound, together with morphological examination helped us create a dynamic array of the central nervous system development.

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

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9. Prognostic markers in the pathology of cardiac failure: echocardiography and autonomic nervous system dysfunction

Elena Cristina Enciu, Silviu Marcel Stanciu, Dumitru Matei, Adrian Costache

Introduction: Chronic heart failure is a major health problem worldwide and despite the therapeutic advances, the mortality and morbidity still remain high. Echocardiography is the gold standard for left ventricular function assessment and may provide prognostic information for predicting future heart failure events. Patients and Methods: We analyzed the main echocardiographic markers used for the prognostic of chronic heart failure patients such as the ejection fraction, diastolic impairment and the collapse of inferior vena cava. Also, another parameter is studied, recently recognized as a marker for future cardiac events: autonomic nervous dysfunction. The current paper makes a comprehensive approach of the echocardiographic markers recommended for the diagnosis and follow-up of heart failure adapted to what we really find in our everyday practice with a correct patient management in a clinical and biological context. Even though left ventricle ejection fraction is the most often used parameter for cardiac failure follow-up and prognostic, new and more accurate parameters should be used: Tissue Doppler Imaging and Heart rate recovery - which may become a therapeutic target in the era of cardiac rehabilitation. Conclusions: There is no stand-alone marker for the assessment of cardiac failure; each of the parameters presented has its advantages and its pitfalls. Echocardiography allows a morphologic study, which should always be correlated with clinical and functional studies (exercise stress test and autonomic nervous system dysfunction).

Corresponding author: Silviu Marcel Stanciu, MD, PhD; e-mail: silviu.stanciu@yahoo.com

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10. The histopathological study of radicular dentinal changes in patients with chronic marginal periodontopathies

Melania Olimpia Cojocaru, Elvira Florina Patroi, Dorina Corlan Puscu, Mirela Lucia Opri, Monica Mihaela Craitoiu, Laurentiu Mogoanta, Evantia Coles, Vasile Nicolae, Mariana Sabau

Periodontal disease is one of the most frequent conditions in individuals, having major health and social implications. Progressing as a chronic inflammation at the level of tooth support tissues, untreated chronic periodontitis may lead to a premature loss of the dental organ. Even though the main lesions caused by the periodontal disease affect the alveolo-dental ligaments, we tried to highlight the presence of certain lesions of radicular dentine in patients with chronic marginal periodontopathy. In our study, in the patients with chronic marginal periodontopathy, at periodontium level, there was highlighted the presence of a chronic inflammatory process with numerous lymphocytes and macrophages, microhemorrhages, and also areas with tissular necrosis. At radicular dentine level, in the cases of old, untreated periodontal disease, there were observed areas of more or less extended demineralization, erosion and necrosis. Our study showed that chronic periodontal disease may affect the tooth, as well, not only its support tissues.

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

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11. Proximal tibial osteosarcoma in young patients: early diagnosis, modular reconstruction

Razvan Ene, Ruxandra Diana Sinescu, Patricia Ene, Dan Popescu, Monica Mihaela Cirstoiu, Florin Catalin Cirstoiu

Osteosarcoma is the most common bone tumor that occurs in children and young adults with prevalence of teenage. There can be identified many subtypes of osteosarcoma by how they look on X-rays and under the microscope. Osteosarcoma can be classified as high-grade, intermediate grade, or low-grade. This has a significant prognostic value of tumor development suggesting the growth rate and the potential for expansion. Between 2009-2013, in the Department of Orthopedics and Traumatology, University Emergency Hospital of Bucharest, Romania, were treated seven cases of osteosarcoma of the proximal third of the tibia in young, early-diagnosed cases without metastasis. The treatment involved resection of tumor formation and reconstruction with a modular prosthesis. Postoperative patients were mobilized for a week without charging the operated limb under the protection of orthesis. During this period continued active and passive mobilization of the ankle and foot to prevent stiffness and to reduce postoperative swelling. From the second postoperative week, patients are mobilizing with progressive charging but not being allowed to do any flexion in order to protect de insertion of medial gastrocnemius muscle rotation flap used to cover the prosthesis and to protect the patellar tendon reinsertion. This extensive surgery does not improve survival rate of these patients compared to treatment by amputation of this pathology but greatly increases the comfort of life and in all cases ensure socio-professional reintegration of these patients. To ensure optimal postoperative results perform a complete diagnosis and preoperative oncological treatment before surgery, if applicable.

Corresponding author: Razvan Ene, MD, PhD; e-mail: razvan77ene@yahoo.com

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12. Comparative analysis of microvessel density quantified through the immunohistochemistry expression of CD34 and CD105 in rectal cancer

Dan Silviu Goldis, Mircea Florin Sferdian, Cristian Tarta, Lazar Octavian Fulger, Bogdan Dan Totolici, Carmen Neamtu

Endothelial cells are highlighted using a variety of endothelial markers. One of the best known markers is CD34, a surface antigen. The most used immunohistochemical marker for identification of activated endothelial cells is CD105. We chose to compare these two markers in order to evaluate angiogenesis of the rectal cancers by determining the microvessel density (MVD). Our study included 31 patients with rectal cancer between 2010-2014, who underwent rectal resection at Arad and Timisoara Counties Hospitals, Romania. We used MVD quantification by highlighting the tumor blood vessels with two different endothelial markers using the immunohistochemical protocols. The CD34 evaluation of MVD was 37 vessels/field/x200 peritumoral (PT), compared with normal rectal mucosa with 17 vessels/field/x200. Intra-tumoral (IT) MVD for CD34 positive vessels was between 7 and 120 vessels/field/x200. Average IT MVD CD105+ was 13.7 vessels/field/x200, the PT MVD CD105+ was 10 vessels/field/x200. Usually, IT MVD CD105 is smaller than PT MVD CD105, a pattern that was not respected in our study. There was a statistical significant correlation between IT MVD CD34 and PT MVD CD34 with p=0.008, also IT MVD CD34 and IT MVD CD105 with p=0.009, PT MVD CD34 with PT MVD CD105, p=0.001. PT MVD CD34 had a statistical significant correlation with T, p=0.004. IT MVD CD105 associated with T, p=0.004, and with N, p=0.004. The evaluation of both CD34-CD105 showed the role of angiogenesis in the cancer proliferation and local spread, the angiogenesis level being maintained high even in the advanced stages of the disease. There was observed a difference between the intratumoral and peritumoral MVD, the study of this difference possibly leading to a better assessment of prognosis and adjusted therapies in the future.

Corresponding author: Bogdan Dan Totolici, MD; e-mail: totolici_bogdan@yahoo.com

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13. Immunohistochemical aspects of apoptosis in gingival mucosa with papilloma and condyloma acuminata

Monica Scrieciu, Veronica Mercut, Razvan Mercut, Marina Olimpia Amarascu, Sanda Mihaela Popescu, Anca Mihaela Predescu, Ileana Monica Banita

The oral mucosa is a component of the oral ecosystem, which can be aggressed by corrosion products released from the dental alloys used in prosthetic dentistry therapy. The purpose of this study was to compare the in vivo effect of nickel and copper compounds on the oral mucosa cells, including their ability to induce cell death, by analyzing the cytochrome c (cyt. c) immunohistochemical expression. Gingival mucosa fragments obtained from the subjects with dentures manufactured by nickel or copper casting alloys were processed through the histological technique of paraffin inclusion. The sections obtained were stained by usually histological methods in order to highlight the histopathological lesions and also analyzed using the immunohistochemical technique in order to study the cyt. c expression. The papillomatosis lesions were observed in the gingival mucosa fragments obtained from the subjects with nickel-based alloy dentures and the condyloma acuminata lesions were observed in those obtained from the subjects with copper-based alloy dentures. The cyt. c immunohistochemical expression was different in the epithelial layer of two types of mucosal fragments but it was the same in their lamina propria connective tissue. We can conclude that the two types of metal alloys have different effects on the adjacent gingival mucosa.

Corresponding author: Monica Scrieciu, Associate Professor, MD, PhD; e-mail: scrieciu_monica@yahoo.com

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14. Influence of Staphylococcus aureus attachment to the herpes simplex virus infected cells

Coralia Bleotu, Mariana Carmen Chifiriuc, Veronica Lazar, Roxana Dragusel, Lilia Matei, Ioana Madalina Aldea, Laura Denisa Dragu, Bogdan Ionescu, Carmen Cristina Diaconu, Costin Cernescu, Carmen Aurelia Mogoanta, Cristian Radu Popescu, Bogdan Popescu, Raluca Grigore, Serban Vifor Gabriel Bertesteanu

The purpose of this study was to investigate the response of HeLa cells to the interaction with inactivated Staphylococcus aureus cells and live challenge with herpes simplex virus (HSV).The results of this study are indicating that the interaction between the HeLa cells and S. aureus inactivated whole cells could modulate the host cell apoptosis and cytokine production, and therefore, influence the progression of HSV infection. The pre-treatment of HeLa cells with heat inactivated bacterial whole cells protects them from the occurrence of HSV mediated cytopathic effect, while the post viral infection treatment with bacterial cells prevents the high activation of bax/bcl-2 apoptotic pathway, a process that could change the fate of the infectious process triggered by the virus, and eventually reduce its multiplication rate. The pre-treatment of HeLa monolayer with inactivated bacterial cells 24 hours before the viral infection is increasing the expression level of TNF-alpha, IL-6 and IL-8 pro-inflammatory cytokines genes, also suggesting that bacterial antigens could contribute to the decrease of viral multiplication rate.

Corresponding author: Raluca Grigore, Lecturer, MD, PhD; e-mail:raluca.grigore@3f.ro

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15. Histopathological aspects described in patients with chronic hepatitis C

Florin Petrescu, Octavia Ileana Petrescu, Citto Iulian Taisescu, Maria Victoria Comanescu, Mircea Catalin Fortofoiu, Ion Octavian Predescu, Alexandra Floriana Rosu, Cristian Gheonea, Viorel Biciusca

Chronic hepatitis C affects an estimated 170 million people worldwide and causes approximately 350 000 deaths each year. The current antiviral therapy allows the virus eradication or the permanent inhibition of the virus replication (sustained virological response, SVR), the reduction of the inflammation, and the prevention or the reduction of liver fibrogenesis (histological response). We studied the histopathological aspects found during percutaneous liver biopsy in patients with chronic hepatitis C viral infection who were treated and monitored over a period of two years. The assessment of the histological activity index through Ishak score determined the presence of: mild chronic hepatitis in 12 (23.1%) patients, moderate chronic hepatitis in 21 (40.4%) patients, and severe chronic hepatitis in 19 (36.5%) patients. The percutaneous liver biopsy performed on the patients with chronic viral hepatitis C showed a series of histological alterations, the most frequent being: portal inflammation, periportal necrosis, lobular inflammation, focal necrosis, and hepatic fibrosis (scarring). The severity degree of this histopathological aspect was correlated with the hepatitis activity index. The association of piecemeal with bridging necrosis is the deadline at which the antiviral treatment can still be effective. Evidence of early fibrosis represent the important moment for the antiviral treatment start. The specific histopathological aspects, but not pathognomonic, of chronic hepatitis C (hepatic steatosis, portal lymphoid infiltrates and bile duct damage) had a reduced incidence, occurring in only half (hepatic steatosis), a quarter (portal lymphoid infiltrates) and a fifth (destruction of biliary ducts) of all the patients with chronic viral hepatitis C, and these patterns was correlated with advanced degree of necroinflammatory process of the liver, particularly in the portal tracts.

Corresponding author: Citto Iulian Taisescu, Lecturer, MD, PhD; e-mail: taisescu@yahoo.com

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16. Fenugreek powder exerts protective effects on alcoholised rats kidney, highlighted using ultrastructural studies

George Ciprian Pribac, Mircea Florin Sferdian, Carmen Neamtu, Constantin Craciun, Corina Luminita Rosioru, Aurel Ardelean, Bogdan Dan Totolici

Trigonella foenum-graecum (TFG) seeds exert a protective antioxidant effect and membrane protector through their rich content in polyphenolic flavonoids. The previous research focused on the hypoglycemic action of the seeds, with scarce studies on the preventive effects in the pathology of the kidney. Our work was conducted on an experimental in vivo model; the animals were given two different concentrations of TFG seeds, consequently to alcohol intoxication. Transmission electron microscopy (TEM) analysis showed vacuolation in cytoplasm, edemas at the apical pole of the nephrocytes, diffusion of the cytoplasmic and mitochondrial matrix and the increase in number of the lysozymes and especially peroxisomes, as well as the congestion of blood capillaries. In the case of the groups T5R and T10R, which received Trigonella powder together with ethanol, the structural and ultrastructural changes produced by the ethylic intoxication were more reduced, being somewhat improved in the T5R group. Therefore, the majority of the cells nuclei have retained their spherical shape, being at the same time predominantly euchromatic, with little heterochromatin and evenly dispersed. Our results suggest the use of Trigonella seeds as a food supplement to prevent cellular deterioration and improve renal morphology and function.

Corresponding author: Carmen Neamtu, Senior Lecturer, MD, PhD; e-mail: carmen.neamtu@gmail.com

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17. Considerations on morphological abnormalities of permanent teeth in children with cleft lip and palate

Anca Maria Raducanu, Andreea Cristiana Didilescu, Ion-Victor Feraru, Mihaela Adina Dumitrache, Tudor Alexandru Hantoiu, Ecaterina Ionescu

Oral clefts are commonly associated with dental anomalies of number, size, shape, structure, position and eruption affecting both dentitions. Dental malformations may affect the development, growth and functions of the dento-maxillary apparatus (chewing, aesthetics, speech). The purpose of this paper was to assess the dental morphological variations in a group of patients with cleft lip and/or palate (CLP), as compared with a group of healthy subjects. The study sample included 48 patients with various types of CLP (15 girls and 33 boys) aged between 12.6 years and 17.3 years. The control group (without CLP) consisted of 1447 patients (545 girls and 903 boys). The proportion of patients with dental shape anomalies in the control group was 8.6%, while the proportion of patients with dental shape anomalies in the CLP group was 56.3% (p<0.01). With this regards, the frontal area was more affected in CLP group than controls. The most common morphological abnormality in the control group was supplementary cusp, while in the CLP sample it was dilaceration. Teeth from the dental hemiarch affected by CLP were most affected in their morphology.

Corresponding author: Ion-Victor Feraru, Assistant Professor, DMD; e-mail: victor.feraru@gmail.com

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18. Genetic polymorphisms of TNFA and IL-1A and generalized aggressive periodontitis

Teodora Virginia Barnea, Anca Sava, Carmen Gentimir, Ancuta Goriuc, Otilia Boisteanu, Liliana Chelaru, Roxana Irina Iancu, Catalina Anda Avram, Dragos Daniel Acatrinei, Elena Geanina Bogza, Oana Cristina Raducanu, Daniel Petru Cioloca, Decebal Vasincu, Marcel Costuleanu

Virulent bacteria could cause gingival fibroblasts apoptosis through lipopolysaccharide release during generalized aggressive periodontitis (GAgP) development and evolution. We showed that treatment with lipopolysaccharide (LPS, 1 micro-g/mL) for 30 days induced the decrease in the number of cultured rat gingival fibroblasts as compared to control group, which received no treatment. GAgP is considered to have also a genetic etiology, so the aim of our study was to evaluate if some polymorphisms of tumor necrosis factor-alpha (TNFA) and interleukin 1A (IL-1A) genes are associated with GAgP in a sample of Romanian population. We selected a group of 32 subjects (22 cases and 10 controls) for studying the TNFA (-857) polymorphism and 97 subjects (66 cases and 31 controls) for IL-1A (-889) polymorphism. The single nucleotide polymorphisms were genotyped by real-time polymerase chain reaction for all subjects. The genotype and allelic distribution tended to be equally between the cases and the controls group. Similar results were obtained for the dominant and recessive model. The difference between the two groups did not reach statistic significance for neither of the two studied polymorphisms [p=0.76 for TNFA (-857) and p=0.84 for IL-1A (-889)]. The data suggest that TNFA (-857) C/T and IL-1A (-889) C/T polymorphisms are not associated with susceptibility to GAgP in this Romanian population, potentially because of the small sample size. This is the first such study for Romanian northeastern population.

Corresponding author: Decebal Vasincu, Assistant Professor, MD, PhD; e-mails: deci_vas@yahoo.com, decebal.vasincu@umfiasi.ro

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19. Immunolocalization of VEGF-A and orosomucoid-1 in odontogenic myxoma

Ronell Bologna-Molina, Adalberto Mosqueda-Taylor, Hugo Dominguez-Malagon, Sirced Salazar-Rodriguez, Gabriel Tapia, Rogelio Gonzalez-Gonzalez, Nelly Molina-Frechero

Objective: The aim of the present study was to determine and establish the immunohistochemical distribution of VEGF-A and ORM-1 protein in odontogenic myxomas to suggest a possible function in the biological behavior of odontogenic myxomas. Materials and Methods: A total of 33 odontogenic myxoma cases and three tooth germs were included. Immunohistochemistry was performed to localize VEGF-A and ORM-1 proteins in tumor cells, endothelial cells and extracellular matrix in the odontogenic myxomas. The intratumoral microvessel density (MVD) was determined with CD34 and Factor VIII antibodies. Results: Immunopositivity was strong in the endothelial cells, which compose various vessels, and in the randomly oriented stellate, spindle-shaped and round tumoral cells with long cytoplasmic processes. More than half of the extracellular matrix lacked expression of VEGF-A. ORM-1 expression was strong in both endothelial cells and tumor cells, and the myxoid extracellular matrix was positive, with moderate or strong immunoexpression in all cases. An important finding of this study was the statistically significant positive correlation between the expression of ORM-1 and VEGF-A in tumor cells (p=0.02). Conclusions: The results of this study suggest that the expression of VEGF-A and ORM-1 may be associated with two mechanisms (angiogenesis and tumor structural viscosity) that may influence tumor growth in odontogenic myxoma.

Corresponding author: Ronell Bologna-Molina, DDS, PhD; e-mail: ronellbologna@hotmail.com

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20. Comparative study of HER2, EGFR, p53 and PTEN expression in the human gastrointestinal tract during fetal period

Alexandru Ghizdavat, Gergo Raduly, Zsuzsanna Pap, Lorand Denes, Zoltan Pavai

Introduction: HER2, EGFR, p53 and PTEN are important in organization of the germ layers, in embryonic development and morphogenesis, in the development and differentiation of certain organ systems and in embryonic morphogenesis. Our goal is the comparative examination of the expression of these markers in the digestive tract of 9-24-week-old fetuses. Materials and Methods: We studied using immunohistochemical techniques esophagus, stomach, small and large intestine tissue samples collected from 18 post mortem fetuses of 9-24 weeks. Results: HER2 and PTEN expression appears as early as the 9-12 weeks period in the digestive tract, but HER2 expression decreases in the 21-24 weeks period and then disappears. EGFR expression appears only during the 13-16 weeks period. The expression of p53 is strong until week 21, and then it is restricted to the deeper layers of the epithelium. Conclusions: Our findings suggest that these markers have role also in the fetal period and complete the scarce data found in literature about the expression of the studied markers in the development of the digestive tract.

Corresponding author: Zsuzsanna Pap, Associate Professor, MD, PhD; e-mail: papzsuzsa@yahoo.com

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21. Interrelations between hepatic stellate cells and immune system cells in patients with hepatocellular carcinoma

Alin Gabriel Ionescu, Sergiu Marian Cazacu, Costin Teodor Streba, Mircea Catalin Fortofoiu, Marius Eugen Ciurea, Mihaela Ionescu, Otilia Rogoveanu, Violeta Comanescu, Stefan George Firu, Cristin Constantin Vere

Objective: Our aim was to identify potential correlations between activated hepatic stellate cells (HSCs) and immune system s cells in patients with viral C hepatocellular carcinoma, by quantifying the percentage of activated HSCs, T-lymphocytes, natural killer cells and B-lymphocytes, in three distinct regions: tumor, transition area and the vicinity tissue (2-5 mm). Patients and Methods: We prospectively included 20 samples prelevated at necropsy from patients with HCC and C viral infection. We assessed the percentage of alpha-smooth muscle actin (alpha-SMA), CD45RO, NK1 and CD20 expression using immunohistochemistry and a semi-quantitative scoring method. Results: We found an inverse correlation between the number of alpha-SMA-positive HSCs and the number of NK1-positive cells in tumor (p=0.0007), in the transition area/tumor capsule (p=0.024) and in the vicinity tissue (p=0.038). Regarding T-lymphocytes, we have also identified an inverse correlation with the number of alpha-SMA-positive HSCs in tumor (p=0.0036), in the transition area/tumor capsule (p=0.034) and in the vicinity tissue (p=0.047). We found no correlation between the number of activated HSCs and the number of CD20-positive cells in all three examined areas. Conclusions: The analysis of HSCs activity within specified areas of tumoral liver tissue may lead to new perspectives in early diagnosis of relapses and in the development of future neoadjuvant therapies.

Corresponding author: Sergiu Marian Cazacu, Lecturer, MD, PhD; e-mail: cc.vere.umf@gmail.com

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22. Ultrasonography-histopathology correlation in major salivary glands lesions

Cecilia Petrovan, Diana Maria Nekula, Simona Liliana Mocan, Toader Septimiu Voidazan, Adina Cosarca

Major salivary glands display a various and complex pathology, showing different evolution and prognosis, depending on the histopathological form. The choice of an appropriate treatment plan for the best outcome, therefore the proper surgical approach, would imply preoperative knowledge of the histopathological diagnosis. However, any core-biopsy performed prior to surgery presents the risk of a false result and increases the difficulty of latter surgery. Therefore, some complementary examinations are used, among these, ultrasonography. The retrospective study (April 2010-March 2013) conducted in the Clinic of Oral and Maxillofacial Surgery, Emergency County Hospital, Tirgu Mures, Romania, aims to evaluate the relevance of the ultrasonography by itself in leading towards a proper preoperative assessment and diagnosis, and thus, in choosing the proper treatment plan. The study included 33 lesions of the major salivary glands, undergoing first ultrasonography, then curative surgery. Different characteristics (shape, dimension, consistency, vascularization, homogeneity, delimitation) were assessed on ultrasonography as well as on histopathology; finally, the correlation between those two examinations was evaluated, by comparing diagnoses. The results of our study are similar to others, showing that ultrasonography can diagnose preoperatively the majority lesions of major salivary glands. The conclusions of the study sustain the importance of ultrasonography as a routine examination in major salivary glands lesions.

Corresponding author: Diana Maria Nekula, MD; e-mail: dianapopu@yahoo.com

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23. Clinical and histological aspects with therapeutic implications in head and neck lymphomas

Mihail Tusaliu, Carmen Aurelia Mogoanta, Camelia-Marioara Dobrea, Viorel Zainea

Malignant lymphoma (ML) is one of the major issues in modern medical practice, with an increasing incidence in recent years, which makes it, together with leukemia, the most frequent form of neoplasia affecting young people. The onset can occur both inside and outside the lymph nodes, with a quarter of the lymphomas with extranodal onset being located in the head and neck. The purpose of the paper is to conduct a retrospective study over a period of six years on patients diagnosed and admitted to the clinic with malignant lymphomas located in the head and neck, discussing their different histological variations. It emphasizes the importance of the histopathological examination and, in particular, of the immunohistochemical tests, in determining the histological subtype of the lymphoma, as the immunohistochemical and cytogenetic data of the malignant cell play a major role in the evolution and prognosis of patients. The study leads to the conclusion that, in spite of the advancements of the immunological, cytogenetic and molecular techniques, the diagnosis and histological determination of malignant lymphomas continue to be a challenge to clinicians and anatomical pathologists. Of particular importance in the efforts made for the accurate diagnosis and proper treatment of the ENT (ear, nose and throat) malignant lymphomas is the interdisciplinary collaboration between the ENT specialist, the hematologist, the anatomical pathologist, the oncologist and the nutritionist.

Corresponding author: Mihail Tusaliu, MD, PhD; e-mail: mtusaliu@yahoo.com

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24. Human placenta - stem cell source for obtaining pancreatic progenitors

Sergiu Susman, Dan Rus-Ciuca, Olga Soritau, Razvan Ciortea, Mihai Girlovanu, Dan Mihu, Carmen Mihaela Mihu

Objectives: The apparition of sugar diabetes is produced by the decrease of the number and capacity of beta cells to secrete insulin. Cell mass recovery through cell therapy might be one of the solutions for treating this disease. The use of various cell sources of different differentiation grades has been tried over the last years. Decoding the molecular mechanisms of the pancreatic morphogenesis is essential for obtaining cells having a phenotype, which would be very similar to the mature cells located in the pancreatic endocrine component. In this study, in order to obtain pancreatic progenitors, we used stem cells harvested from the mesenchymal component of the amniotic membrane, cells with particular immunological properties, which are effective in transplant. Materials and Methods: Isolated cells from the placenta (amniotic membrane) have undergone a three-stage differentiation protocol. The modulation of glucose concentration, the type of substrate (collagen + laminin) and the use of nicotinamide and exedin-4 were the main selective conditions of differentiation microenvironment. The differentiated cells were analyzed from the point of view of proteins (immunofluorescence - IF), gene expression (real-time polymerase chain reaction - RT-PCR) and morphological changes. Results: Isolated cells from the placenta membrane induced for pancreatic differentiation expressed transcription factors, which are characteristic for pancreatic progenitors (Pdx1 and PAX4). During the experiment, the cells modified their morphology by forming islet-like clusters. They were positively for dithizone staining and expressed insulin as shown by immunocytochemistry. Conclusions: The isolated cells from the placenta can be differentiated towards pancreatic progenitors by using specific protocols.

Corresponding author: Sergiu Susman, Lecturer, MD, PhD; e-mail: serman_s@yahoo.com

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25. A nonfunctional neuroendocrine tumor of the pancreas - a case report

Stelian Stefanita Mogoanta, Adrian Costache, Gabriela Mutiu, Simona Gabriela Bungau, Mirela Ghilusi, Florin Grosu, Manuela Vasile, Ionica Daniel Vilcea, Mircea Constantin Gherghinescu, Laurentiu Mogoanta, Daniela Adriana Ion

Pancreatic neuroendocrine tumors (pNETs) represent about 1-5% of the pancreatic tumors, having an annual incidence of about 1/100 000, with difficult positive and differential diagnostic, especially in nonfunctioning tumors. We present a case of large dimensions (10/8 cm) pancreatic tail NET developed in a 65-year-old woman, incidentally discovered while she was examined for a strangled inguinal hernia. The patient had no specific tumor signs and the imagistic examination did not reveal any metastases. The histopathological and especially the immunohistochemical examinations were decisive for the diagnosis, treatment and prognostic establishment. The tumor showed intense positivity for chromogranin, synaptophysin, CD56, CD117, CK19, MNF-116 and negative for CK5/6 and CK7. The proliferative index established through the Ki-67 assessment was around 3%, while p53 was positive in 25-30% of tumor cells nuclei.

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

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26. Tuberculosis of the oral cavity

Roxana Maria Nemes, Edith Simona Ianosi, Corina Silvia Pop, Paraschiva Postolache, Costin Teodor Streba, Mihai Olteanu, Andreea-Loredana Golli, Madalina Olteanu, Mimi Floarea Nitu

Tuberculosis (TB) of the tongue is not a common finding diagnosis, even if consider endemic areas. Tuberculosis of the tongue sometimes can mimic lingual neoplasm. Oral tuberculosis is rarely primary as mechanism, and frequently secondary to pulmonary tuberculosis. There are many suspect lesions that can be classified as tuberculosis, such as tumor mass, ulcerative lesion or fissure. It is very important for diagnosis to perform histopathological examination of the biopsy. We present here the case of a 74-year-old man who developed lingual tuberculosis with a tumor aspect concomitant with pulmonary tuberculosis. Histopathological and immunohistochemical examinations established the diagnosis of lingual tuberculosis.

Corresponding author: Costin Teodor Streba, Teaching Assistant, MD, PhD; e-mail: costinstreba@gmail.com

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27. Papillary thyroid carcinoma with anaplastic dedifferentiation in the lymph node metastasis - a rare form of presentation even for a tall cell variant

Carmen Gabriela Barbu, Andrei Florin, Marius Cristian Neamtu, Elena Taina Avramescu, Dana Terzea, Adrian Miron, Rucsandra Danciulescu Miulescu, Catalina Poiana, Simona Fica

Papillary thyroid carcinoma (PTC) is well known as a differentiated thyroid carcinoma with an established treatment protocol and high survival rates. Nevertheless, its tall cell variant (TCV) is more frequent diagnosed with larger tumor size, advanced age and metastasis comparing to other PTC cases, resembling an increased level of aggressiveness attributable to the histological subtype according to recent studies. We present the case of a 60-year-old woman who came for a recently increase of the thyroid and a left laterocervical mass associated with pain and alteration of general status. Thyroidectomy revealed a TCV of PTC with infiltration of the extrathyroid tissue. The laterocervical mass posed difficulties to surgical excision but in a second attempt proved to be an undifferentiated carcinoma. The findings were associated to a rapid deterioration of the patient s general condition finalized with death within less than three months from the initial presentation.

Corresponding author: Carmen Gabriela Barbu, Associate Professor, MD, PhD; e-mail: carmen_gabriela_barbu@yahoo.co.uk

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28. Segmental aganglionosis in Hirschsprung s disease in newborns - a case report

Radu Ninel Balanescu, Laura Balanescu, Andreea Alecsandra Moga, Gabriel Cristian Dragan, Florin Bogdan Djendov

Segmental aganglionosis Hirschsprung s is an extremely rare condition. Described as a segment of normally ganglionated bowel surrounded proximally and distally by aganglionosis, zonal aganglionosis is of interest because it may cause confusion in interpreting surgical margins. Diagnosis of segmental lesions in Hirschsprung s disease may be missed as it is rarely suspected at initial surgery. We report the case of a 2-week-old baby girl admitted to our clinic for abdominal distension and vomiting. Considering the family history (near total colonic aganglionosis in a 2-month-old sister with unfavorable outcome), the suspicion of Hirschsprung s is raised and serial large intestine biopsies are taken. Intraoperatively, a transverse colon stenosis caused by an incomplete web is noticed and segmental colectomy with anastomosis is performed at this level. Histopathological and immunohistochemical results established the diagnosis of segmental transverse colon aganglionosis, with the presence of ganglia cells in the ascending and descending colon. Subtotal colectomy with ascending colon pull-through was performed with favorable postop evolution. In our patient, the association with a transverse colon stenosis raised suspicion concerning the diagnosis of Hirschsprung s disease, but considering the family history, extended biopsies were taken and the correct diagnosis of zonal aganglionosis was established. Although zonal aganglionosis lesions are extremely rare, this case illustrates the point that the presence of ganglia cells at the resection line is not sufficient to guarantee postoperative function. Extended intestinal biopsies should be included in the algorithm for management of long segment Hirschsprung s disease and will enable the surgeon to correctly detect zonal aganglionosis.

Corresponding author: Laura Balanescu, MD; e-mail: laura7balanescu@yahoo.com

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29. Perineal reconstruction with biologic graft vulvoplasty for verrucous carcinoma treated by repeated vulvar excisions: a case report

Elvira Bratila, Cornel Petre Bratila, Diana-Elena Comandasu, Vasilica Bausic, Doina Mihaela Pop, Vlad Denis Constantin, Monica Mihaela Cirstoiu, Ruxandra Stanculescu

Vulvar neoplasia represents 5% of malignancies in female genital tract and 0.6% of all cancers in women. Although it is known to be a rare type of cancer, which occurs especially in elderly women, its incidence is increasing in young females because of its association with the human papillomavirus (HPV). In this paper, we report the case of a 46-year-old woman, gravidity 4, parity 3, with a medical history of multiple vulvar excisions for recurrent ulcerative vulvar lesions during a period of 11 years. The first lesion appeared in 2003, it was excised and the histopathological result showed squamous cell carcinoma with undifferentiated areas and chronic ulcerative inflammation. The patient underwent radiation therapy remaining at the end of it a small-ulcerated lesion at the superior vulvar commissure, which was biopsied in 2004 showing chronic ulcerative inflammation with reparatory areas of squamous immature benign metaplasia In April 2014, a dermatological consult described vulvar scleroatrophic lichen confirmed by a biopsy. In November 2014, the patient presented to our clinic when a vicious vulvar scar was detected, with a transformed tegument with aspect of atrophic lichen. A perineal reconstruction including anal sphincter plasty was performed. Due to the important remaining skin defect, a Surgisis graft vulvoplasty was performed. The histopathological result of the excised suspect areas was vulvar intraepithelial high-grade neoplasia (VIN III). A retrospective histopathological review of the case established that is more accurate to consider that the vulvar lesions were, all along, a very well differentiated squamous cell carcinoma (verrucous carcinoma), which lacks cytopathic effect of HPV infection, has a low p53 expression but a high Ki67. Case evolution was favorable with the acceptance and integration of the biologic grafts at two months after surgery and normal healing.

Corresponding author: Elvira Bratila, University Assistant, MD, PhD; e-mail: elvirabarbulea@gmail.com

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30. Incidental finding of a sclerosing hemangioma in a Caucasian woman

Mihai Danciu, Tiberiu Lunguleac, Cristina Grigorescu

Sclerosing hemangioma of the lung is a rare and mostly benign lung tumor, which affects especially Asian middle-age women (median age of 48 years). We report the case of a 27-year-old woman in which, a premarital routine chest X-ray investigation revealed a 2 cm well-defined opaque nodule in the lower left pulmonary lobe, confirmed by CT scan. Microscopically, the surgically enucleoresected nodule was represented by a heterogenic tumor (papillary, solid, sclerotic, hemorrhagic patterns), containing two cell populations: cuboidal surface epithelial cells lining the papillary structures and round stromal cells in solid areas, with distinct immunoprofile and low mitotic activity, consistent with sclerosing hemangioma. This case is particular because, being rare in Caucasian persons, intraoperative diagnosis on frozen sections is extremely difficult, and routine histopathological diagnosis needs immunohistochemical tests to set the correct diagnosis, hence the correct therapeutic attitude.

Corresponding author: Tiberiu Lunguleac, MD, PhD student; e-mail: dr_tiby@yahoo.com

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31. Arteriovenous synovial hemangioma of the popliteal fossa diagnosed in an adolescent with history of unilateral congenital clubfoot: case report and a single-institution retrospective review

Zoltan Derzsi, Simona Gurzu, Ioan Jung, Ileana Laszlo, Mircea Golea, Ors Nagy, Tudor Sorin Pop

Synovial hemangioma (SH) is a very rare soft tissue tumor; in our department, SH represented 0.07% from all soft tissue tumors (one case from 1311 soft tissue tumors), and 0.78% from all excised hemangiomas (one case from 128 hemangiomas) diagnosed over a five-year period. The aim of this paper was to present the clinicopathologic characteristics of hemangiomas and particularities of one SH of the popliteal fossa diagnosed in an athletic adolescent with previously corrected congenital clubfoot. To our knowledge, this is the 275 case of reported SH. A 13-year-old trick cyclist presented with two-year history of slowly growing mass of the left posterior fossa. The magnetic resonance imaging of the left knee showed a juxta-articular mass with intramuscular component. Open excision of the tumor and partial removal of the synovial membrane was the therapy of choice. Histopathological examination revealed clusters of large arteries and veins embedded in a fibrotic tissue, the tumor mass being lined by synovial membrane. Intramuscular growing was also confirmed. Without any other postoperative therapies, no recurrence or functional disorders were noted after 21 months of follow-up. SH of the knee should be excised as soon as possible to avoid complications such as muscle invasion and risk of recurrence.

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

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32. A case of hairy cell leukemia variant

Amelia Maria Gaman, Camelia-Marioara Dobrea, Mihnea-Alexandru Gaman

Hairy cell leukemia variant (HCLv) is a rare B-cell chronic lymphoproliferative disorder with features of the classic HCL but presenting some particularities, a poor response to conventional therapy of classic HCL and a more aggressive course of disease with shorter survival than classic HCL. We present a case of a 52-year-old man hospitalized in July 2012 in the Clinic of Hematology of Craiova, Romania, having splenomegaly, leukocytosis with lymphocytosis, anemia and thrombocytopenia, without monocytopenia, which exposed, in the peripheral blood and bone marrow cells, intermediate morphology between hairy cells and prolymphocytes and immunophenotype of mature B-cell phenotype CD19, CD20, CD22, CD11c, CD103, low positive for CD25 and negative for CD3, diagnosed with HCL variant, with no response to conventional chemotherapy and interferon-alpha, an aggressive course of disease and a survival of less than a year from diagnosis.

Corresponding author: Amelia Maria Gaman, Professor, MD, PhD; e-mail: gamanamelia@yahoo.com

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33. Single ectopic thoracic renal artery associated with a normal kidney position and renal artery stenosis: a case report and review of literature

Petru Matusz, Gratian Dragoslav Miclaus, Abigail Gabriel, Ilia Catereniuc, Sorin Olariu, R. Shane Tubbs, Marios Loukas

There are several reports of multiple ectopic renal arteries (RA) in the literature. However, the ectopic origin of a single RA with a normal kidney position is rare. Knowledge of this variant is extremely important in clinical, surgical and radiological practice. Using MDCT angiography examination, we describe a rare case of a right kidney located in a normal lumbal position with a single ectopic thoracic renal artery originating in the thorax, above the diaphragmatic dome, at the level of the upper one-third of the T12 vertebral body. With an S -shaped course and a total length of 103 mm, this artery had an intratoracic portion of 38 mm. It crossed the diaphragm at 23 mm lateral to the right side of the TA, through a hiatus located on the lateral side of the right crus of the diaphragm. The right inferior phrenic artery arose from the left lateral wall of the right RA, 5 mm below the level of CT (45 mm distal to the right RA origin). Remarkably, this variant was associated with an area of proximal arterial stenosis, which produced signs and symptoms of hypertension secondary to renal arterial stenosis. To the authors knowledge, this is the first reported case of a stenotic single ectopic thoracic renal artery associated with a normal kidney position.

Corresponding author: Sorin Olariu, Associate Professor, MD, PhD; e-mail: srnolariu@yahoo.com

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34. Pyoderma vegetans of the posterior area of the neck: case presentation

Cristian Mesina, Ion Vasile, Stelian Stefanita Mogoanta, Marius Eugen Ciurea, Horia Parvanescu, Theodor Viorel Dumitrescu, Claudia Valentina Georgescu, Daniela Ciobanu

Pyoderma vegetans is a rare disease characterized by the presence of vegetant exudative, pustular and erythematous vesiculobullous plaque usually located in the inguinal area and axillary fold. Etiology of pyoderma vegetans is unknown but it is often associated with bacterial infections in immunocompromised patients. Main histopathological characteristics of pyoderma crops are pseudoepitheliomatous hyperplasia and subepidermal, intraepidermal neutrophilic or eosinophilic microabscesses. It is well known that these lesions are commonly associated with colonic inflammatory disease such as ulcerative colitis and Crohn s disease. Not available standard treatment for pyoderma vegetans, although the use of antibiotic therapy was often used with variable results. Standard first-line therapy is the systemic steroids yet. We perform excision of the lesion of the posterior area of the neck with application of the free split-thickness skin graft after 48 hours postoperatively. In this paper, we present a case of pyoderma vegetans with unusual location without associating colonic lesions and a review of literature related to therapeutic and diagnostic problems of this disease.

Corresponding author: Cristian Mesina, Assistant Professor, MD, PhD; e-mail: mesina.cristian@doctor.com

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35. An immunocompetent young patient with tuberculosis of the penis: a challenging case

Maria Rotaru, Sorina Taban, Mona Taroi, Virgil Patrascu, Florina-Ligia Popa

Tuberculous chancre is an extremely rare form of cutaneous tuberculosis. The genital area is a possible site of presentation. We present a case of a young male with a persistent balanopreputial ulceration resembling a luetic chancre with negative serology for syphilis. The diagnosis was based on the specific pathologic features and the positive intradermal reaction to tuberculin. A successful treatment was achieved by combining antituberculosis treatment and surgical approach with circumcision. After six months of antituberculosis treatment, the patient developed paradoxical inguinal lymph node enlargement, which, after surgical excision and biopsy, was not followed by a relapse of the disease and needed no further therapy. Tuberculosis should be considered a potential diagnosis in the case of a persistent genital ulcer.

Corresponding author: Sorina Taban, Associate Professor, MD, PhD; e-mail: sorinataban@yahoo.com

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36. Duplication of the distal end of the left vertebral artery with fenestration of the right posterior cerebral artery

Horia Ples, Marios Loukas, Nicoleta Iacob, Naomi R. Andall, Gratian Dragoslav Miclaus, R. Shane Tubbs, Petru Matusz

The vertebrobasilar system (VBS) consists in the intracranial parts of the vertebral arteries (VAs), the basilar artery (BA) and its branches. The presence of a duplication at the level of the intracranial segment of VA (V4) is generally an incidental finding, but may be associated with aneurysms or arteriovenous malformations. We present an extremely rare case of duplication of the distal end of the left vertebral artery, associated with fenestration of the right posterior cerebral artery. The distal end of the left VA was duplicated into two arms (the right with a length of 5.5 mm and a diameter of 2.3 mm that connected with the contralateral VA; and the left with a length of 11.0 mm and a diameter of 1.6 mm, which connected more distally with the BA). The right posterior cerebral artery (PCA) had a fenestration in the posterior segment of the posterior communicating part (P2), with a length of 6.8 mm.

Corresponding author: Gratian Dragoslav Miclaus, MD, PhD; e-mail: gratianmiclaus@yahoo.com

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37. Upper airway cavities morphologic features in facial asymmetries

Elina Teodorescu, Matei Crisan, Viorica Tarmure, Elena Galan, Stefan Milicescu, Ecaterina Ionescu

Facial asymmetries have an important impact on the cranio-facial structures morphology, being the result of the genetic, environmental and dysfunctional factors and their impact on the dento-maxillary complex. Asymmetries can be identified in all craniofacial structures, including the upper airway cavities. Craniofacial asymmetries can influence general growth and development by altering the respiratory function. The present study aimed to evaluate morphologic correlations of the upper airway cavities changes in facial asymmetries. Most of the cases included in the study showed on the underdeveloped side that the nostril and nasal fossa were narrowed, while the paranasal sinuses were frequently larger. However, no correlation could be established to answer whether these changes were determined by asymmetry, or if they appeared as compensatory, or if only some structures of the upper airway cavities changed morphologically in a compensatory manner.

Corresponding author: Elina Teodorescu, Associate Professor, DDS, PhD; e-mail: elinateodorescu@yahoo.com

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38. Intrapartum diagnostic of Roberts syndrome - case presentation

Razvan Vladimir Socolov, Nicoleta Ioana Andreescu, Ana Maria Haliciu, Eusebiu Vlad Gorduza, Florentin Dumitrache, Raluca Anca Balan, Maria Puiu, Mihaela Amelia Dobrescu, Demetra Gabriela Socolov

Roberts syndrome is a rare disease, with multiple limb and skeletal abnormalities (called pseudothalidomide disease ). There are only around 150 cases described in literature. We present a case of Roberts syndrome, diagnosed in moment of delivery, after a pregnancy without prenatal follow-up. The stillborn baby was naturally delivered by a 17-year-old primiparous woman at 38 weeks of amenorrhea. The pregnancy was not followed due to socioeconomic and family situation, and no prenatal ultrasound was performed. The male baby has 2650 g and presented several morphological abnormalities and tight double umbilical abdominal loop. The macroscopic evaluation showed: dolichocephaly, hypoplastic inferior maxilla with micrognathia, antimongoloid palpebral slant, pterygium colli, abnormal and lower implanted ears, superior limbs phocomelia, syndactyly at lower left limb and tetradactyly in all limbs, bilateral cryptorchidism, pancreatic aplasia. Roberts syndrome is a rare genetic disease with recessive autosomal transmission generated by mutations in ESCO2 gene, located on chromosome 8. The disease should be easy to diagnose by antenatal ultrasound examination, but in our case, the lack of prenatal follow-up determined the diagnostic at term. We believe consider this case is an argument towards introducing ultrasound-screening compulsory to all pregnancies. To identify a possible genetic mutation, further investigations of the parents are in progress, but classically the disease has a recessive autosomal transmission.

Corresponding author: Nicoleta Ioana Andreescu, University Assistant, MD, PhD; e-mail: nicollandreescu@yahoo.com

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39. Clinical and histological characterization of an aggressive periodontitis case associated with unusual root canal curvatures

Stefan-Ioan Stratul, Alexandra Roman, Petra Surlin, Stefan Adrian Petrutiu, Petronela Buiga, Carmen Mihaela Mihu

The article presents the histological and clinical characteristics in a severe generalized aggressive periodontitis case associated with multiple root curvatures and the complex therapeutic approach of the severe periodontal destructions. The patient received a complex therapy, including periodontal non-surgical, regenerative and reconstructive approaches, and also endodontic and prosthetic treatments. Recall appointments were fixed at 3-month intervals. One year after the finalization of the active therapy, a hyperplasic, inflamed interdental papilla associated with a recurrent clinical attachment loss was diagnosed at the mesial aspect of the right maxillary second premolar. A biopsy was harvested for histological examination and the recurrent site was treated. The histological study revealed important modifications of the epithelial layer and of the connective tissue of the gingiva. An extremely accentuated pattern of the gingival rete ridges at the epithelial-connective tissue junction, the presence of inflammatory cells infiltrating the epithelial layer and lamina propria and the disorganization of the fascicules of collagen fibers were observed. The inflammatory infiltrate was dominated by plasma and monocytic-like cells as immunohistochemical analyses highlighted. The complex therapeutic approach led to a satisfactory aesthetic and functional outcome. The severe root curvatures may be an unusual trait in this generalized aggressive periodontitis case substantially increasing the amount and the costs of non-periodontal procedures. In this case, the cell make-up of the inflammatory infiltrate and the paucity of collagen in the infiltrated tissue portions are considered to correspond to a fully developed recurrent lesion.

Corresponding author: Alexandra Roman, Professor, PhD; e-mail: veve_alexandra@yahoo.com

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40. Localized laryngeal amyloidosis - a case report

Mihaly Szocs, Gheorghe Muhlfay, Simona Liliana Mocan, Andor Balazs, Radu Mircea Neagoe

Amyloidosis encompasses a variety of conditions, caused by extracellular, insoluble protein fibrils that disturb the normal functioning of cells and organs. The disease may be localized or systemic, hereditary or acquired (associated with chronic inflammatory or hematological diseases). We present the case of a 49-year-old woman, with symptoms including dysphagia, dysphonia and dyspnea. After taking the case history and performing clinical examination, we suspected a laryngeal tumor to be the cause of the symptoms. Microlaryngoscopy and biopsy were performed. The histopathological examination result of the biopsy specimen was amyloidosis. Surgical excision of the tumor was performed. Our case presentation describes this rare pathological finding, its clinical manifestations, the histopathological and surgical diagnostic problems, treatment, patient evolution and the difficulties we encountered along the way, through the scope of our personal experience.

Corresponding author: Gheorghe Muhlfay, Associate Professor, MD, PhD; e-mail: ghe.muhlfay@gmail.com

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41. Uterus neuroendocrine tumor - a severe prognostic factor in a female patient with alcoholic cirrhosis undergoing chronic hemodialysis

Ruxandra Diana Sinescu, Andrei Niculae, Ileana Peride, Florina Vasilescu, Ovidiu Gabriel Bratu, Dan Liviu Dorel Mischianu, Mariana Jinga, Ionel Alexandru Checherita

There is increased evidence that end-stage renal disease patients, especially the hemodialyzed population, may present various unexpected forms of complications, contributing to a poor prognosis. Furthermore, neuroendocrine tumors, rarely encountered in daily practice, present in dialyzed individuals can significantly exacerbate the inflammatory condition with negative impact on patients quality of life. We present an unusual case of uterus neuroendocrine tumor with multiple metastases in a 49-year-old female hemodialyzed patient with a history of alcoholic liver cirrhosis and uterus fibromatous. Multiple endoscopic techniques (e.g., upper endoscopy, colonoscopy, upper and lower echoendoscopy), histological evaluation of biopsy samples from involved areas (the operatory piece) were performed in order to complete and refine the diagnosis.

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

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42. Fulminant evolution in one case of choroidal melanoma - predictive factors for general metastasis

Carmen-Luminita Mocanu, Maria-Rodica Manescu, Mihaela Coroi, Andreea-Gabriela Deca, Stefania Craitoiu

Comparing with other malignant tumors, uveal melanomas determine tardive general spreading. Even in the absence of local treatment, general metastasis is less than 20%, in the first five years, many factors being involved. This paper present a particular case of choroid melanoma with very unusual and unpredictable evolution of the disease; the high growth of tumor size (in only half year the tumor almost doubled up dimensions), was associated with hepatic metastasis developed in only several months. In our opinion, this case, presenting a very atypical evolution may contribute to increase our knowledge of the mechanisms underlying metastasis and the identification of reliable progression parameters as prognostic markers in primary uveal melanoma. Several histological characteristics and demographic factors have been associated with disease evolution: presence of retinal neovessels and neovascular glaucoma, rapid increasing tumor thickness, scleral invasion, epithelioid cell types with large nucleoli, lymphocytic infiltration, and vascular pattern with networks of loops. Sclera invasion is uncommon in choroid tumors, but it is associated with an unfavorable bad prognosis, giving a great propensity to metastasize and to affect the liver. The median survival following diagnosis of hepatic metastasis is only several months.

Corresponding author: Maria-Rodica Manescu, Associate Professor, MD, PhD; e-mail: rodicam.manescu@yahoo.com

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43. The involvement of upper airway in Wegener s granulomatosis - about four cases

Cristian Andrei Sarau, Daniel Florin Lighezan, Ion Caius Doros, Eugen Horatiu Stefanescu, Gheorghe Iovanescu, Nicolae Constantin Balica, Ioana Delia Horhat, Marioara Poenaru

The authors present four cases of Wegener s granulomatosis patients with multiorganic manifestation forms, but with a prevalent involvement in upper-airway. Granulomatosis diseases of the nose include bacterial infections (rhinoscleroma, tuberculosis, syphilis, lupus, and leprosy), fungal infections (rhinosporidiosis, aspergillosis, mucormycosis, candidosis, histoplasmosis, and blastomycosis) and diseases with unspecified etiology (Wegener s granulomatosis, mediofacial malignant granuloma, and sarcoidosis). We consider an interesting experience regarding Wegener s granulomatosis due to its rarity, being an autoimmune systemic disease, with continuous evolution and multiorganic involvement. The beginning of the disease is like upper airway affection, a kind of persistent cold , being difficult to differentiate it from a common cold in the head, with a prolonged evolution. It is important to mention that we establish the diagnosis of Wegener s granulomatosis starting with Ear Nose and Throat (ENT) clinical exam, followed by other tests and investigations realized in our Clinic and completed with specialty tests (nephrology, internal medicine and dermatology), meaning that we need a close cooperation with these medical specialties. All the patients presented multiorganic involvement. Notably significant for our four cases is the prolonged evolution in a stable condition in one patient.

Corresponding author: Marioara Poenaru, Professor, MD, PhD; e-mail: marioara.poenaru@gmail.com

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44. Neuroendocrine pancreatic tumor - diagnosis circumstances, staging and treatment: a case report

Gabriela Jimborean, Edith Simona Ianosi, Alexandra Diana Comes, Simona Gurzu, Mimi Floarea Nitu, Georgeta Delia Luput, Tibor Mezei, Oliviu Cristian Borz

Neuroendocrine neoplasms (NENs) of the pancreas are rare and frequently malignant. Our presentation of a pancreatic NEN analyzes the diagnosis circumstances, staging, treatment, one-year evolution and disease particularities. A 39-year-old nonsmoker patient was admitted in the Clinic of Pulmonology, Tirgu Mures, Romania with a pneumonia suspicion (fever, thoracic pain irradiated below the diaphragm, mild dyspnea). The chest X-ray showed a rise of the left diaphragm. Abdominal ultrasound revealed a large pancreas-related tumor. Computerized tomography (CT) scan with contrast confirmed a well-vascularized pancreatic tumor, which invades spleen, collateral circulation of the splenic vein, enlarged liver without secondary lesions and no retroperitoneal adenopathies. The patient was referred to the surgery where there was performed total tumor resection, spleen resection, and large lymphadenectomy. Histopathology and immunohistochemistry revealed the pancreatic NEN G2 grade, T3N1M0 and allowed accurate treatment. 2010 World Health Organization (WHO) NENs classification recommends further treatment-related biomarkers determination only in selected cases. Our case evolution after one year was favorable without local tumor relapse or metastases. The close survey of the patient (by clinical exam, imaging and biological markers) is ongoing. The onset of asymptomatic pancreatic tumor may have atypical respiratory symptoms. Imaging methods (ultrasound, contrast CT) are recommended in borderline symptomatology. Radical surgical resection of the tumor with lymphadenectomy, histopathology with immunohistochemistry play an essential role in the correct diagnostic, grading, staging and treatment of pancreatic NENs. Close survey of the clinical, imagistic and biological markers is recommended.

Corresponding author: Edith Simona Ianosi, Lecturer, MD, PhD; e-mail: ianosi_edith70@yahoo.com

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