ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 57 No. 2, 2016

1. The molecular mosaic of the premalignant cutaneous lesions

Doinita Olinici, Laura Gheuca-Solovastru, Laura Stoica, Laurentiu Badescu, Pavel Onofrei, Emanuela Ana Botez, Carmen Elena Cotrutz

In the last three decades, the premalignant cutaneous lesions have represented a milestone for the clinicians and the anatomopathologists given the increased risk of malignant transformation not only in the old but also in the young population. Recent research indicates the fact that, though multiple progresses were recorded in the diagnosis and treatment of the cutaneous squamocellular carcinomas, developed in more than 85% of the cases in premalignant lesions, however the prognosis and survival up to five years did not register significant improvements. For the achievement of the diagnosis with certainty, the histopathological examination, considered until recently the golden standard, principally based on the TNM criterion, has an increased percentage of subjectivity and it is relatively unsure, being known the fact that two apparently identical tumors answer differently to the same therapy. The variability of the morphological aspects from simple dysplasia to in situ carcinomas and the cancers themselves impose the identification of some cellular and molecular markers typical to the premalignant and malignant cutaneous lesions. In this respect, the knowledge and characterization of the molecular mosaic allow the establishment of some clear criterion for an early diagnosis, corresponding monitoring and adequate treatment.

Corresponding author: Carmen Elena Cotrutz, Professor, MD, PhD; e-mail: cotrutz@yahoo.com

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2. Molecular mechanisms underlying neurodevelopmental disorders, ADHD and autism

George Mihai Badescu, Madalina Filfan, Raluca Elena Sandu, Roxana Surugiu, Ovidiu Ciobanu, Aurel Popa-Wagner

Neurodevelopmental disorders such as attention deficit hyperactivity disorder and autism represent a significant economic burden, which justify vigorous research to uncover its genetics and developmental clinics for a diagnostic workup. The urgency of addressing attention deficit hyperactivity disorder comorbidities is seen in the chilling fact that attention deficit hyperactivity disorder (ADHD), mood disorders, substance use disorders and obesity each increase the risk for mortality. However, data about comorbidity is mainly descriptive, with mechanistic studies limited to genetic epidemiological studies that document shared genetic risk factors among these conditions. Autism and intellectual disability affects 1.5 to 2% of the population in Western countries with many individuals displaying social-emotional agnosia and having difficulty in forming attachments and relationships. Underlying mechanisms include: (i) dysfunctions of neuronal miRNAs; (ii) deletions in the chromosome 21, subtelomeric deletions, duplications and a maternally inherited duplication of the chromosomal region 15q11-q13; (iii) microdeletions in on the long (q) arm of the chromosome in a region designated q21.1 increases the risk of delayed development, intellectual disability, physical abnormalities, and neurological and psychiatric problems associated with autism, schizophrenia, and epilepsy and weak muscle tone (hypotonia); (iv) interstitial duplications encompassing 16p13.11.

Corresponding author: Ovidiu Ciobanu; e-mail: ovidiu.ciobanu@upkbs.ch

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3. Bringing cardiac stem cell therapy from bench to bedside: lessons from the past and future perspectives

Miruna Mihaela Micheu, Alexandru Scafa-Udriste, Maria Dorobantu

Findings in the cardiology field from the last three decades of the 20th century were ruled by the theory that the heart is a post-mitotic organ, incapable to regenerate. Recent studies have brought evidences regarding the existence of some cells residing in the adult heart, having stem properties. These cardiac stem cells (CSCs) govern myocardial homeostasis and repair by differentiating into new cardiomyocytes, smooth muscle cells and vascular endothelial cells and also by releasing proangiogenic and procardiogenic cytokines. Hence, CSC-based therapy seems to be a promising tool for repairing failing hearts. This review presents the current data regarding various subpopulations of CSCs and their regenerative potential revealed by phase I clinical trials; finally, future perspectives for the development of more advanced therapeutic protocols are proposed.

Corresponding author: Miruna Mihaela Micheu, MD; e-mail: mirunamicheu@yahoo.com

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4. Wearable sensors used for human gait analysis

Daniela Tarnita

This paper briefly presents recent developments in the field of wearable sensors and systems that are relevant to the area of normal and pathological human gait analysis. By using wearable sensors, it is possible to monitor the pathological gait disorders and alterations and the changes of balance in the people and prevent or diagnose of different diseases. The most usable wearable sensors and their applications in clinical field are presented based on specialty literature.

Corresponding author: Daniela Tarnita, Professor, PhD; e-mail: tarnita.daniela@gmail.com

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5. Explants-isolated human placenta and umbilical cord cells share characteristics of both epithelial and mesenchymal stem cells

Diana Maria Anastasiu, Ada Cean, Maria Florina Bojin, Adrian Gluhovschi, Carmen Panaitescu, Virgil Paunescu, Gabriela Tanasie

In recent years, identification of new sources of adult stem cells developed rapidly, pursuing to find easily available tissues, which will give rise to homogenous stem cells populations. Up to present, bone marrow-derived mesenchymal stem cells (BM-MSCs) are unanimously considered to fulfill the criteria for being used in clinical settings, but adipose stem cells, placental and umbilical cord stem cells, and other tissue-derived stem cells are making their way to being used at least in autologous transplantation. We isolated cellular populations from placental tissue and umbilical cord using the explants method. The placental (PL) and umbilical cord (UC)-derived cells were cultured and expanded in appropriate conditions for generation of stem cells. We assessed the stemness characteristics of the tissue-isolated cells and compared them to an established MSCs line. For this purpose, we determined the immunophenotype, morphological and ultrastructural characteristics, as well as functional abilities of PL- and UC-derived cells. Flow cytometric evaluation of cells revealed presence of CD90, CD73, and CD105 stem cells markers, while the cells were negative for CD34, CD45 and HLA-DR. Immunocytochemical staining showed that 100% of PL- and UC-derived cells are positive for vimentin and CD105 expression, while cytokeratin was revealed in less than 10% in both tissue-isolated cells. Morphological and ultrastructural characteristics of cells exposed analogous cellular size and intracellular organization, similar to MSCs, but detailed view of UC-derived cells by transmission electron microscopy (TEM) demonstrated presence of intercellular junctions-desmosomes, similar to epithelial cells. Both PL- and UC-derived cells confirmed their trilineage potential, being able to differentiate into adipocytes, osteoblasts, and chondrocytes in different proportions. Flow chamber in vitro assay was used to determine to what extent PL- and UC-derived cells are able to adhere to substrates (VCAM and ICAM) and we showed progressively decreased adhesion of both cellular types, inversely proportional to the generated shear stress. We may conclude that explants-isolated placental and umbilical cord cells are endowed with characteristics of both epithelial and mesenchymal stem cells, and purification procedures are additionally required for safe use of these cells in diverse clinical applications.

Corresponding author: Ada Cean, Biotech Engineer, PhD; e-mail: teleaada@gmail.com

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6. Clinico-statistical and morphological aspects of severe traumatic brain injuries

Charoula Florou, Andreea Lavinia Zorila, Marian Valentin Zorila, Magdalena Alice Marinescu, Cristina Maria Andrei, Raluca Maria Pavaloiu, Laurentiu Mogoanta, Roxana Eugenia Zavoi

Traumatic brain injuries (TBIs) represent a problem of public health all over the world if we consider its incidence, mortality and the big social costs. The increase of road and train traffic, the development of industry, the growth of alcohol consumption, the emergence and increase of terrorist attacks have led to more frequent and severe TBIs. There were registered 3260 deaths at the Institute of Forensic Medicine in Craiova, Romania, between 2010 and 2014; they were the result of severe traumas, 622 (19.07%) being caused by TBIs. The most affected by TBIs were men (the men/women ratio was of 3/1) and the elderly, mainly in the rural area. The main risk factor was alcohol intake; about 44% of the deceased people were under alcohol influence. The forensic examination highlighted the severity of cerebral meningeal lesions, the most frequent being cerebral and vascular lesions. The histopathological and immunohistochemical examinations emphasized various microscopic changes in accordance with the severity of the trauma and the time passed from impact until death.

Corresponding author: Marian Valentin Zorila, MD, PhD; e-mail: zorilavaly@yahoo.com.au

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7. Clinical and pathological considerations on renal diseases in patients with chronic viral hepatitis

Vlad-Florin Iovanescu, Adriana Florentina Constantinescu, Costin Teodor Streba, Sorin-Ioan Zaharie, Cristin Constantin Vere, Eugen Mandache, Mircea Niculae Penescu, Eugen Mota

Chronic viral hepatitis B and C may associate different extrahepatic manifestations and renal disease is the most frequent. Kidney damage is represented in most cases by glomerulopathies, which include membranous nephropathy, membranoproliferative glomerulonephritis (MPGN), IgA nephropathy, focal and segmental glomerulosclerosis and diabetic nephropathy. We conducted a retrospective study on 639 patients diagnosed with chronic viral hepatitis B and C and different renal diseases. Complete evaluation of liver and renal status was performed and, in selected cases, renal biopsy. The evaluation of our cases allowed us to uncover that 82 (12.8%) patients presented a renal disease that could be linked to the viral infection. In order to identify the histopathological type of the renal lesions, kidney biopsy was performed in 39 of our patients. In hepatitis B virus (HBV) infection, the most frequent glomerulopathy was represented by membranous nephropathy, while in chronic hepatitis C infection, MPGN was responsible for the majority of glomerulonephritis. Most patients with MPGN and hepatitis C virus (HCV) also presented mixed cryoglobulinemia. Immunoglobulin A (IgA) nephropathy was present in both liver diseases while diabetic nephropathy was only found in HCV infection, in the context in which chronic hepatitis C is a risk factor for the development of type II diabetes mellitus.

Corresponding author: Vlad-Florin Iovanescu, PhD Student; e-mail: iovanescu_vlad@yahoo.com

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8. The evaluation of Ki67, p53, MCM3 and PCNA immunoexpressions at the level of the dental follicle of impacted teeth, dentigerous cysts and keratocystic odontogenic tumors

Adina-Simona Cosarca, Simona Liliana Mocan, Mariana Pacurar, Emoke Fulop, Alina Ormenisan

The aim of this study is to analyze the immunoexpression of Ki67, p53, MCM3 and PCNA markers in epithelial remnants of dental follicles of impacted teeth and to identify a possible correlation between the immunoexpression of these markers in dentigerous cysts and keratocystic odontogenic tumors in order to evaluate their evolutionary behavior. Materials and Methods: A total of 102 cases were included in the study and divided into three subgroups: the first subgroup consisted of 62 cases with dental follicles of impacted teeth, the second included 20 cases of dentigerous cysts and the third subgroup comprised a number of 20 cases with keratocystic odontogenic tumors. Immunomarking with the four antibodies was performed. Results: A positive marking was obtained in over 60% of the dental follicles for all markers. Statistically significant differences were also obtained in dentigerous cysts and keratocystic odontogenic tumors for Ki67, p53 and MCM3. Assessment of the four antibodies in the two layers of keratocystic odontogenic tumors shows a positive correlation between Ki67 and MCM3 both for the basal and parabasal layer, with slightly increased values in the latter. Conclusions: In order to determine the proliferative capacity of epithelial remnants in the dental follicles, Ki67 and PCNA, Ki67 and MCM3 are the most useful markers in practice; they have similar behavior and are more likely to help in distinguishing between dentigerous cysts and keratocystic odontogenic tumors.

Corresponding author: Emoke Fulop, Lecturer, PhD; e-mail: emifulop@yahoo.com

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9. GPER and ERalpha expression in abnormal endometrial proliferations

Andrei-Adrian Tica, Oana-Sorina Tica, Claudia Valentina Georgescu, Daniel Pirici, Maria Bogdan, Tudorel Ciurea, Stelian Stefanita Mogoanta, Corneliu Cristian Georgescu, Alexandru-Cristian Comanescu, Tudor-Adrian Balseanu, Raluca Niculina Ciurea, Eugen Osiac, Ana-Maria Buga, Marius Eugen Ciurea

G-protein coupled estrogen receptor 1 (GPER), a particular extranuclear estrogen receptor (ER), seems not to be significantly involved in normal female phenotype development but especially associated with severe genital malignancies. This study investigated the GPER expression in different types of normal and abnormal proliferative endometrium, and the correlation with the presence of ERalpha. GPER was much highly expressed in cytoplasm (than onto cell membrane), contrary to ERalpha, which was almost exclusively located in the nucleus. Both ERs densities were higher in columnar epithelial then in stromal cells, according with higher estrogen-sensitivity of epithelial cells. GPER and ERalpha density decreased as follows: complex endometrial hyperplasia (CEH) > simple endometrial hyperplasia (SHE) > normal proliferative endometrium (NPE) > atypical endometrial hyperplasia (AEH), ERalpha density being constantly higher. In endometrial adenocarcinomas, both ERs were significant lower expressed, and widely varied, but GPER/ERalpha ratio was significantly increased in high-grade lesions. Conclusions: The nuclear ERalpha is responsible for the genomic (the most important) mechanism of action of estrogens, involved in cell growth and multiplication. In normal and benign proliferations, ERalpha expression is increased as an evidence of its effects on cells with conserved architecture, in atypical and especially in malignant cells ERalpha s (and GPER s) density being much lower. Cytoplasmic GPER probably interfere with different tyrosine/protein kinases signaling pathways, also involved in cell growth and proliferation. In benign endometrial lesions, GPER s presence is, at least partially, the result of an inductor effect of ERalpha on GPER gene transcription. In high-grade lesions, GPER/ERalpha ratio was increased, demonstrating that GPER is involved per se in malignant endometrial proliferations.

Corresponding author: Oana-Sorina Tica, MD, PhD; e-mails: oana.banica@umfcv.ro, oanabanica25@yahoo.com

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10. Radiological, histological and immunohistochemical evaluation of periapical inflammatory lesions

Antonela-Marcela Berar, Cosmina-Ioana Bondor, Luminita Matros, Radu-Septimiu Campian

The loss of teeth is largely caused by supporting tissue damage, because of bacterial invasion from the infected root canals. Sixty patients with periapical lesions (PLs) of endodontic origin were included in the study. Clinical and radiological examination was performed. Periapical radiographs were analyzed by two independent observers to determine the size and severity of PLs, using Periapical Index (PAI) scores. The tissue samples collected by periapical curettage during apicoectomy or after dental extractions by alveolar curettage were histologically and immunohistochemically analyzed. The PLs were histologically diagnosed as: periapical granulomas (PGs), granulomas with cystic potential and radicular cysts (RCs) with various degrees of inflammation. Capillary density was evaluated using the angiogenic index after immunohistochemical staining with CD34 monoclonal antibody. A statistically significant correlation was observed between PAI scores and the size of the lesions. 68.33% of cases were PGs, 18.33% PGs with cystic potential and 18.33% RCs with different degrees of inflammation. Seventy-five percent PLs had an angiogenic index 1 and 25% had an angiogenic index 2. Statistically significant differences were obtained between the angiogenic index and lesion size (p<0.05). Capillary density within PLs did not influence the severity scores of lesions detected on radiographs. The angiogenic index appeared not to be associated with the histological lesion type and the intensity of inflammation, but was more likely correlated with the degree of granulation tissue maturation and the size of PLs.

Corresponding author: Antonela-Marcela Berar, Teaching Assistant; e-mail: antonela_berar@yahoo.com

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11. Local cause of gingival overgrowth. Clinical and histological study

Emma Cristina Draghici, Stefania Craitoiu, Veronica Mercut, Monica Scrieciu, Sanda Mihaela Popescu, Oana Andreea Diaconu, Bogdan Oprea, Roxana Maria Pascu, Monica Mihaela Craitoiu

The overgrowth, depending on its extension, has multiple effects on the stomatognathic apparatus: functional disorders (impaired speech), difficulty in chewing and aesthetic problems but can cause significant psychological problems. We proposed this study, motivated by the relative increased frequency of the gum outgrowth, its multifactorial etiopathogeny, but especially from the point of view of the specialist practitioner, by the problems that this pathology raises not only for the functionality of the stomatognathic apparatus but also for the facial esthetics, and especially for future therapeutic attitudes needed to solve the existing pathology at this level. We conducted a clinical study and a histological one. For the clinical study, we selected 74 patients who experienced different degrees of gingival outgrowing associated with fillings, dental caries, fixed prostheses, mobile prostheses, orthodontic apparatus. Thirty gingival fragments from patients with gingival outgrowing were processed by paraffin-embedding histological technique and stained with Hematoxylin-Eosin. The morphological results obtained provide the necessary support for understanding the possibility of developing a therapeutic strategy to prevent or minimize the gum outgrowth by administering antibiotic and anti-inflammatory medications associated with medications, which shall cause the apoptosis of the fibroblasts.

Corresponding author: Stefania Craitoiu, Professor, MD, PhD; e-mail: scraitoiu@yahoo.com

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12. Experimental study in order to assess the effects of limited periosteum stripping on the fracture healing and to compare osteosynthesis using plates and screws with intramedullary Kirschner wire fixation

Tiberiu Paul Neagu, Valentin Enache, Ion Cocolos, Mirela Tiglis, Cristian Cobilinschi, Radu Tincu

There are many studies that investigate indirect and direct fracture healing but few mention the effect of periosteum stripping on consolidation of fractures. Most of these studies use only one method of osteosynthesis for each group. Therefore, we reported a new developed murine model in order to assess if limited periosteum stripping influence significantly the quality of the fracture healing process by comparing two different osteosynthesis methods to reduce simultaneously bilateral femur fractures. We applied the experimental protocol for a number of 12 rats. We used plates and screws to reduce femoral osteotomy for the right hind limb and intramedullary Kirschner wire for the left hind limb. Clinical, radiological and histological assessments were made for a period of eight weeks. The absence of a healthy hind limb led to a slower healing process based on the histological findings and to implant failure based on radiological findings. In summary, complete fracture healing was not achieved during this experimental study. Therefore, we consider that future studies are needed for a better understanding of the effects of periosteum removal on the fracture healing process.

Corresponding author: Tiberiu Paul Neagu, Assistant Professor, MD; e-mail: dr.neagupaul@gmail.com

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13. Histoprognostic markers role in colorectal cancer

Florinel Badulescu, Gabriela-Marcelina Mihai, Adriana Badulescu, Ileana Prejbeanu

Malignant tumors with digestive location are, according to the World Health Organization (WHO), a major cause of morbidity and mortality worldwide. In Romania, the constant increase of prevalence and incidence of colorectal cancer awarded it the status of priority public health problem. The study aimed to identify specific aspects of colorectal cancer histoprognosis that may be associated with a higher frequency of the disease. Data were collected from records and registers within Clinic of Medical Oncology, Emergency County Hospital, Craiova, Romania. Were analyzed and associated demographics and epidemiological data, clinical features, anatomotopographical, histopathological and immunohistochemical. The cases studied were adenocarcinomas with a balanced gender distribution and a worrying incidence for Craiova. The age group with the highest incidence was that of 55-64 years. Topographic, rectum and rectosigmoidian junction are the first two locations. More than half of the cases (55.55%) are adenocarcinomas with moderate differentiation and belong to the pT3 category, as extension of colorectal tumor degree. 32.5% of patients were identified with mutations in the K-Ras oncogenes and were found Ki67 positive immunoreacted and heterogeneity of antigen expression in tumor areas studied. Colorectal cancer recorded a worldwide steady increase in the incidence; growth trend in our country is above the European average. Dolj County faces with an increased incidence and mortality rates by this disease. To limit the disease at the population level and pre-malignant diagnosis is necessary to establish histo-prognostic value and predictive of tumor markers.

Corresponding author: Florinel Badulescu, Professor, MD, PhD; e-mail: fbadulescu2001@yahoo.com

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14. Protective role of alpha lipoic acid against polychlorobiphenyl (Aroclor 1254)-induced testicular toxicity in rats

Ozay Gules, Ulker Eren

The present study was aimed to investigate the antioxidant, biochemical, and histological effects of alpha lipoic acid (ALA) on polychlorinated biphenyl (PCB)-induced testicular toxicity in male rats. The rats were divided into five groups: In the control group, the rats were not administered any chemicals for 30 days. In the sham group, the rats were administered corn oil for 30 days. In the PCB group, the rats were administered with Aroclor 1254 for 30 days. In the ALA group, the rats were treated with ALA for 30 days. In the ALA+PCB group, the rats were treated with ALA 24 hours before Aroclor 1254 was administered for 30 days. The total oxidant status (TOS) level in the serum and testis, number of apoptotic cells, vacuolization at the basal membrane, immature spermatids in the tubular lumen, heme oxygenase-1 (HO-1) staining density, and abnormal spermatozoa were significantly increased in the PCB group. Moreover, in the PCB group, the seminiferous tubule diameter (STD) was decreased in stage VII-VIII and XII-XIV tubules. The TOS level in the serum and testis, vacuolization at the basal membrane, immature spermatids in the tubular lumen, and apoptosis were significantly decreased in the ALA+PCB groups. These findings suggested that ALA has a protective role against PCB-induced testicular toxicity.

Corresponding author: Ozay Gules, Assistant Professor; e-mail: ogules35@gmail.com

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15. An application of microscopic investigation on extracted premolar with dyschromia, related to the components of endodontic sealer

Ioana Suciu, Ecaterina Ionescu, Costin Varlan, Oana Elena Amza, Sinziana Adina Scarlatescu, Ileana Suciu, Mihai Ciocirdel, Bogdan Alexandru Dimitriu

The aim of this study was an assessment of the overall optical characteristics changes in volume of the dentin, after the diffusion of the chemical components included in the sealer throughout the endodontic space, in order to demonstrate the discoloration effect of the endodontic sealer on tooth crown of a recently extracted maxillary premolar. Thin sections were studied using the polarized transmitted light microscopy and under a stereomicroscope, operating in transmitted light and reflected light. There were performed serial images of magnitude 40x. Each image was covered by a grid aimed for microscopic sections volumetric measurements. Therefore, all the serial images were merged and resulted a global image of the entire section surface. Thus, we have analyzed a total of three sections of the same tooth. Based on these sets of images, there were made estimations of the areas affected by colorations, determinations that can be extrapolated to total tooth areas, in terms of volumetric color change of dentin. The proportion of low coloristic infiltrated dentin was very close to the deeply impregnated dentin and the overall impregnated dentin covered half of the total dentin analyzed area.

Corresponding author: Ioana Suciu, Associate Professor, DMD, PhD; e-mail: joa_suciu@yahoo.com

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16. A comprehensive analysis of genome-wide association studies to identify prostate cancer susceptibility loci for the Romanian population

George Daniel Radavoi, Catalin Pricop, Viorel Jinga, Dana Mates, Viorica Elena Radoi, Mariana Jinga, Radu Ioan Ursu, Ovidiu Gabriel Bratu, Dan-Liviu Dorel Mischianu, Paul Iordache

The aim of this study is to examine a large dataset of single nucleotide polymorphism known to be associated with prostate cancer from previous genome-wide association studies and create a dataset of single nucleotide polymorphisms that can be used in replication studies for the Romanian population. This study will define a list of markers showing a significant association with this phenotype. We propose the results of this study as a starting point for any Romanian genome-wide association studies researching the genetic susceptibility for prostate cancer.

Corresponding author: Catalin Pricop, Associate Professor, MD, PhD; e-mail: bobopricop@yahoo.com

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17. Clinical and biological outcomes of prolonged treatment with haloperidol in schizophrenia

Mihai Mutica, Ileana Marinescu, Felicia Militaru, Mihail-Cristian Pirlog, Ion Udristoiu

Paranoid schizophrenia with long-term course is a challenge for the clinical and therapeutic research, particularly because chronic course is difficult to identify due to the high rate of mortality in this category of patients. The therapeutic stability on an antipsychotic molecule (haloperidol) is indeed an exception, since the current trend in the case of unfavorable course is based on therapeutic versatility and polypharmacy. Haloperidol is the first-generation antipsychotic that is referred in the therapeutic guidelines as the golden standard regarding its efficacy on positive symptoms. The research in fundamental and molecular psychopharmacology has shown the aggressivity of this molecule on the secondary and tertiary signaling chains, including mitochondrial alterations. On male patients with paranoid schizophrenia (positive symptoms) and a chronic course of more than 35 years who received exclusively haloperidol, our study demonstrated an negative outcome with the loss of social functioning, persistence of positive symptoms, chronic extrapyramidal symptoms and mild cognitive impairment. The neuroimaging evaluations have shown atrophy in the temporal poles, posterior ventriculomegaly, cerebellar atrophy and calcification on choroid plexus and pineal gland. The difference between the histological changes induced by haloperidol on animal model and the ones on the patients in our study is located in the frontal cortex, thus suggesting the presence of two neurobiological models of schizophrenia in men: fronto-striatal and temporal-limbic-striatal. The persistence of extrapyramidal symptoms during the treatment with haloperidol may be considered as a clinical marker of the risk for negative outcome and a potential indication for the therapeutic switch.

Corresponding author: Felicia Militaru, Teaching Assistant, MD; e-mail: feliciobanu@yahoo.com

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18. Multifunctional materials such as MCM-41/Fe3O4/folic acid as drug delivery system

Simona Popescu, Ioana Lavinia Ardelean, Dragos Gudovan, Marius Radulescu, Denisa Ficai, Anton Ficai, Bogdan Stefan Vasile, Ecaterina Andronescu

In this study, MCM-41 mesoporous silica nanoparticles (NPs) and MCM-41/Fe3O4 mesoporous silica NPs were prepared by sol-gel method using CTAB (cetyltrimethylammonium bromide) as template and TEOS (tetraethyl orthosilicate) as silica precursor in order to use these materials as drug delivery system (DDS) for different biologically active agents. The MCM-41 and MCM-41/Fe3O4 mesoporous silica NPs were characterized using specific physico-chemical methods [transmission electron microscopy (TEM), scanning electron microscopy (SEM), nitrogen adsorption and desorption studies - BET (Brunauer-Emmett-Teller) method, X-ray diffraction (XRD) and Fourier transform infrared (FTIR) spectroscopy], while the release studies were done by a high-performance liquid chromatography (HPLC)-modified method. The pH dependence of the delivery of folic acid from the mesoporous structures was analyzed and found that the release is pH sensitive. The lower delivery at strongly acid pH comparing with neutral/slightly alkaline pH could be beneficial because in stomach the folic acid can be destroyed.

Corresponding author: Denisa Ficai; e-mail: denisaficai@yahoo.ro

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19. The complexity of hemorrhage-generating factors in various organs in acute kidney injury

Alexandru Rocsoreanu, Daniela Cernea, Cristiana Eugenia Simionescu, Eugen Mota

Bleeding disorders, associated with macroscopic and microscopic lesions in different organs are frequently found in acute kidney injury (AKI), in the third stage of the RIFLE (risk, injury, failure, loss, end-stage kidney disease) classification, treated by hemodialysis. The study included 81 cases of AKI of various causes (septic, posttraumatic, postoperative, toxic, medical nephropathies). 59.25% of the patients presented various forms of bleeding disorders (gastrointestinal bleeding, meningo-cerebral hemorrhage, epistaxis, hemodialysis vascular access bleeding, etc.). In the deceased patients that underwent necropsy, various bleeding lesions were found, involving the lungs, kidneys, brain, gastrointestinal tract and liver. A physiopathological interpretation of the factors generating these lesions and their impact on the evolution and prognosis was performed. These factors are related to the AKI s etiology, as well as the physiopathological disorders regarding the uremic syndrome and the various therapies required (blood transfusions, hemodialisys, heparin administration, surgery, macromolecule perfusion). In conclusion, multiple factors are involved in causing bleeding disorders in various organs with a major impact on the evolution and prognosis of AKI patients.

Corresponding author: Alexandru Rocsoreanu, MD, PhD Student; e-mail: rocsoreanu_alexandru@yahoo.com

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20. Allele-specific PCR method for identification of EGFR mutations in non-small cell lung cancer: formalin-fixed paraffin-embedded tissue versus fresh tissue

Bogdan Andrei Suciu, Zsuzsanna Pap, Lorand Denes, Klara Brinzaniuc, Constantin Copotoiu, Zoltan Pavai

The study of epidermal growth factor receptor (EGFR) gene mutations in lung adenocarcinoma patients has a special clinical significance in the selection of patients for tyrosine-kinase inhibitor therapy. The aim of this study was to identify patients with EGFR mutations using allele-specific polymerase chain reaction (PCR), from formalin-fixed paraffin-embedded (FFPE) tissue and fresh tissue (FT). Materials and Methods: We performed a retrospective study using 13 cases of FFPE lung adenocarcinoma, and a prospective study using seven fresh samples of lung carcinomas (FT), collected by intraoperative dissection of the tumors. Using the DNA extracted from the FFPE tissue and FT, we attempted to identify deletions of exon 19 and point mutations of exon 21, according to the allele-specific PCR method described by Dahse et al. (2008). Results: In all seven cases of FT (three adenocarcinomas, three squamous carcinomas, one large-cell carcinoma), we identified the wild type allele and the internal control in case of exon 19, and the wild type allele for exon 21, but not the mutated alleles. Considering that no standard method for formalin fixation and paraffin embedding has been implemented at the Laboratory of Pathology, the DNA extracted from these samples became fragmented and damaged, which compromised the results of PCR testing aimed at the detection of EGFR mutations. Conclusions: The presented method can be implemented at our laboratory to identify these mutations from fresh tissue collected during surgical resection. Additionally, standardization of formalin fixation and paraffin embedding of surgical samples is required, in order the enable subsequent processing using molecular biology methods.

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

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21. The microvascular alterations in frontal cortex during treatment with antipsychotics: a post-mortem study

Ion Udristoiu, Ileana Marinescu, Mihail-Cristian Pirlog, Felicia Militaru, Tudor Udristoiu, Dragos Marinescu, Mihai Mutica

Introduction: Schizophrenia is the most severe psychiatric illness, with a biological support in the brain. There is evidence that the adequate dopamine balance in the frontal cortex is associated with a better outcome of the disorder, while the alteration of dopamine mechanism at this level may affect the vascular system leading to secondary neuronal alterations. Our study was conducted post-mortem and its objective was to identify the alterations in the neuronal architecture, in the integrity of the microvascular unit in the frontal cortex of patients treated with potent and excessive D2-blocking antipsychotics. Materials and Methods: We studied post-mortem sections of the frontal cortex of three patients (two women and one man) diagnosed with schizophrenia or schizophrenia-spectrum disorders and treated with antipsychotics for the last 24 months. The slides were prepared according to the classical histopathological protocols. Results: Various alterations were found at the neural and vascular levels in the frontal cortex. The most significant was the neural loss as the result of severe changes in the microvessels (diameter reduction, hyaline and collagen deposits, edema, pinocytosis and vacuolization). Discussion: The evidences shown in our study highlight the fact that antipsychotics with potent antagonist action on D2 receptors may affect the neurovascular unit and small vessels in frontal cortex by altering the balance vasoconstriction-vasodilatation, thus reducing the blood flow and metabolism and generating structural microvascular changes proportional with the level of apoptosis at this level. The functional integrity of the dopaminergic system in frontal cortex depends on the vascular support and the capabilities of the neurovascular unit and any dysfunction increases the neuronal loss with clinically significant changes. Conclusions: The pathological data of our study raises the hypothesis for the pathogenic stages at the level of microvessels in the frontal cortex of the patients with schizophrenia or schizophrenia-spectrum disorders treated with D2-blocking antipsychotics: a stage with functional, reversible alterations that may be correlated with the impairments of working memory and presence of extrapyramidal symptoms and a lesional, irreversible stage with significant deterioration of cognition and global functioning. Further studies are needed to verify this hypothesis.

Corresponding author: Ileana Marinescu, Lecturer, MD; e-mail: marinescu_psy@yahoo.com

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22. Placenta changes in pregnancy with gestational diabetes

Antoine Edu, Cristina Teodorescu, Carmen Gabriela Dobjanschi, Zita Zsuzsana Socol, Valeriu Teodorescu, Alexandru Matei, Dinu Florin Albu, Gabriela Radulian

Placental damage may be responsible for the fetal complications in pregnancies complicated by diabetes. We have analyzed the prevalence of gestational diabetes (GD) in a population of 109 pregnant women, the risk factors and the placental changes associated with gestational diabetes. Tests carried out were oral glucose tolerance test at 24-28 weeks of gestation, using the IADPSG (International Association of Diabetes and Pregnancy Study Groups) criteria for gestational diabetes, glycated hemoglobin, fasting insulin, total cholesterol, high density lipoprotein (HDL)-cholesterol, low density lipoprotein (LDL)-cholesterol, triglycerides, two-dimensional (2D) ultrasound and, also, there were analyzed macro and microscopic placental fragments from pregnant women with/without GD. It has been recorded the weight of placenta at birth and there were analyzed the possible pathological changes. The prevalence of GD was 11.9%. We have applied the direct logistic regression to determine the impact of some factors over the probability of association with gestational diabetes. The most powerful predictor was the placental maturity grade, the patients with decreased maturity grade having chances 52.6 times higher than those with an increased placental maturity grade to associate gestational diabetes. Sizes of placentas in patients with gestational diabetes mellitus were significantly increased than in patients without this diagnosis (p=0.012) from week 24-28. Pathological changes were discovered in six of the 13 placentas of women with gestational diabetes mellitus, independent of the level of glycated hemoglobin (p=0.72). The level of hyperglycemia is only partially associated with the presence of placental changes, which may be caused by other maternal factors.

Corresponding author: Carmen Gabriela Dobjanschi, MD, PhD; e-mail: dgcarmen2004@yahoo.com

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23. Anatomo-clinical correlations in hepatic steatosis in patients with C chronic hepatitis

Ion Cristian Efrem, Octavian Istratoaie, Elena Simona Micu, Cristian Gheonea, Dragos Stefan Lazar, Sineta Cristina Firulescu, Octavian Ion Predescu, Nicoleta Laura Popescu

Hepatic steatosis is a progressive liver disease, frequently met in chronic virus C hepatitis, playing an important role in its evolution towards fibrosis, necroinflammation and the final stage the hepatocellular carcinoma. The present paper studies the correlation between clinico-epidemiological parameters and the pathology test outcome in patients with hepatic biopsies carried out before they began the antiviral treatment. We used the classical histological staining and the immunolabeling. The presence of steatosis is not directly associated with clinico-epidemiological parameters and with the degree of fibrosis and inflammation.

Corresponding author: Octavian Istratoaie, Lecturer, MD, PhD; e-mail: droctavist@yahoo.com

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24. Intramuscular hemangioma of the arm: ultrasonography and pathology features

Marius Eugen Ciurea, Raluca Niculina Ciurea, Andreea Lili Barbulescu, Andreea-Beatrice Chisalau, Cristina Dorina Parvanescu, Sineta Cristina Firulescu, Simona Covei Banicioiu, Paulina-Lucia Ciurea, Ananu-Florentin Vreju

Hemangiomas are between the most frequent soft tissue masses and despite the vascular origin, they do not generate metastases and do not have malignant evolution. They are frequent in childhood and female sex is more frequently affected. If deeply located, these tumors are difficult to diagnose and thus an imaging method is often needed, but conventional radiology is not sufficient. If superficially located, it frequently involves the skin and subcutaneous tissues, but in the deeper layer, they are often intramuscular. Clinical findings of intramuscular hemangioma include swelling, pain and sometimes loss of muscle function.

Corresponding author: Ananu-Florentin Vreju, Lecturer, MD, PhD, MSc; e-mail: florin_vreju@yahoo.com

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25. The value of histopathological diagnosis in the elderly patients with granulomatous dermatoses. Case series

Mihail-Alexandru Badea, Corneliu-Florin Buicu, Anca Ileana Sin, Ovidiu Simion Cotoi, Iudita-Maria Badea, Andreea Luciana Chiotoroiu, Silviu Horia Morariu

Granulomatous inflammations are a particular type of chronic septic or aseptic inflammation, in which infectious or non-infectious agents are difficult to eliminate by the immune system. These are type IV hypersensitivity reactions mediated by pre-sensitized T-lymphocytes cells CD4+ and CD8+ lymphocytes. Disorders included in this category are: tuberculosis, leprosy, syphilis, sarcoidosis, type I diabetes, multiple sclerosis, Crohn s disease and rheumatoid arthritis. At cutaneous level, this pattern of granulomatous reaction is characterized by a chronic inflammation with formation of granulomas consisting of a variable number of histiocytes, multinucleated giant cells and lymphocytes. Granulomatous dermatoses should be differentiated from other primary or secondary lesions affecting the skin such as inflammation or tumors. Often granulomatous dermatoses can be confused with other skin disorders, both clinically and histological. Histopathology examination can add important information and clarify the diagnosis. This paper presents a series of three clinical cases of granulomatous skin occurring in the elderly patients confirmed at histology examination. Clinical and histology criteria were analyzed, along with specific differential diagnosis, based on data from the literature.

Corresponding author: Corneliu-Florin Buicu, MD, PhD; e-mail: florin_buicu@yahoo.com

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26. Cribriform-morular variant of papillary thyroid carcinoma at pediatric age - case report and review of the literature

Andreea Cristiana Brehar, Dana Cristina Terzea, Dumitru Lucian Ioachim, Camelia Procopiuc, Felix Mircea Brehar, Alexandra Catalina Bulgar, Mircea Vasile Ghemigian, Constantin Dumitrache

Cribriform-morular variant of papillary thyroid carcinoma (CMV-PTC) is a rare tumor, which exceptionally occurs at pediatric age. CMV-PTC may develop in patients with familial adenomatous polyposis (FAP) or may be a sporadic tumor. The authors present a case of CMV-PTC in a 10-year-old girl patient without FAP history, who presented with a left neck mass. The patient underwent total thyroidectomy with central compartment neck dissection. Histopathological diagnosis was compatible with cribriform-morular variant of papillary thyroid carcinoma and Hashimoto s thyroiditis. Immunostaining was positive for thyroglobulin, beta-catenin, CD10 and p53. Molecular test showed the absence of BRAF, K-RAS mutations, deletions or duplications of APC (adenomatosis polyposis coli) gene and showed the presence of RET/PTC (rearranged during transfection/papillary thyroid carcinoma) rearrangements. At 32 months follow-up, the patient was without signs of recurrence. This particular form of thyroid carcinoma should raise suspicion of a possible familial cancer syndrome, therefore early diagnosis and thoroughly evaluation, which includes colonoscopy and genetic screening are mandatory.

Corresponding author: Felix Mircea Brehar, Assistant Professor, MD, PhD; e-mail: felixbrehar@yahoo.com

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27. Granulomatous slack skin - seven years follow-up of a case with features of parapsoriasis en plaques, muscle involvement, granulomatous vasculitis, and necrobiotic changes

Aurel Doru Chirita, Irina Margaritescu

Granulomatous slack skin (GSS) represents an extremely rare variant of mycosis fungoides with only 70 cases reported in the literature to date. It is characterized clinically by the occurrence of bulky, pendulous skinfolds, usually located in flexural areas and histologically by an infiltrate composed of small neoplastic T-lymphocytes joined by granulomatous inflammation with scattered multinucleated giant cells containing nuclei arranged in a wreath-like fashion. Since its first description, very rare cases of GSS with muscle involvement, large vessels involvement, or necrobiotic changes have been reported. We present an extraordinary case of GSS with all these unusual features developing in the lesions of the same patient. The long follow-up of seven years allowed us to document the evolution of each lesion. Some lesions appeared and evolved in a manner very reminiscent of those of parapsoriasis en plaques, others were classical GSS lesions, and still others developed large ulcerated lesions. These ulcerated lesions consistently failed to respond to conventional wound therapy, skin directed therapy [retinoids + psoralen combined with ultraviolet A (PUVA)-therapy], and interferon-alpha therapy. Remarkably, the ulcers completely healed when systemic corticosteroids were added. We hence postulate that the ulcers appeared because of large vessel vasculitis rather than tumoral direct destruction.

Corresponding author: Aurel Doru Chirita, MD, Dipl. ICDP-UEMS; e-mail: dorutchirita@yahoo.com

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28. Limb ischemia, an alarm signal to a thromboembolic cascade - renal infarction and nephrectomy followed by surgical suppression of the left atrial appendage

Cosmin Carasca, Angela Borda, Alexandru Incze, Emilian Carasca, Attila Frigy, Horatiu Suciu

We present the case of a 55-year-old male with mild hypertension and brief episodes of paroxysmal self-limiting atrial fibrillation (AF) since 2010. Despite a small cardioembolic risk score, CHA2DS2-Vasc=1 (Congestive heart failure, Hypertension, Age>=75, Diabetes melitus, prior Stroke), the patient is effectively anticoagulated using acenocumarol. In December 2014, he showed signs of plantar transitory ischemia, for which he did not address the doctor. In early January 2015, he urgently presented at the hospital with left renal pain, caused by a renal infarction, diagnosed by computed tomography (CT) angiography. Left nephrectomy was performed with pathological confirmation. He was discharged with effective anticoagulation treatment. Within the next two weeks, he suffered a transitory ischemic event and a stroke, associated with right sided hemiparesis. On admission, AF was found and converted to sinus rhythm with effective anticoagulation - international normalized ratio (INR) of 2.12. Transthoracic echocardiography detected no pathological findings. Transesophageal echocardiography showed an expended left atrial appendage (LAA) with a slow blood flow (0.2 m/s) and spontaneous echocontrast. Considering these clinical circumstances, surgical LAA suppression was decided on as a last therapeutic resort. Postoperative evolution was favorable; the patient is still free of ischemic events, one year post-intervention. Some morphological and hemodynamic characteristics of LAA may add additional thromboembolic risk factors, not included in scores. Removing them by surgical LAA suppression may decrease the risk of cardioembolic events. Intraoperative presence of thrombus makes it an indisputable proof.

Corresponding author: Cosmin Carasca, Resident Doctor, PhD Student; e-mail: cosmincarasca@yahoo.com

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29. Hemophagocytic lymphohistiocytosis: a rare complication of autologous stem cell transplantation

Andrei Colita, Anca Colita, Camelia-Marioara Dobrea, Alina Daniela Tanase, Carmen Saguna, Cecilia-Gabriela Ghimici, Raluca Mihaela Manolache, Silvana Angelescu, Doina Barbu, Florentina Gradinaru, Anca Roxana Lupu

Hemophagocytic lymphohistiocytosis (HLH) is a very severe and rare syndrome of pathologic immune activation characterized by cytopenia and clinical signs and symptoms of extreme inflammation. HLH is usually fatal without treatment so that accurate and timely diagnosis is very important. The syndrome occurs as a familial disorder (familial HLH - FLH) or as an acquired condition (secondary - sHLH) in association with a variety of pathologic states: infections, rheumatologic, malignant or metabolic diseases. Malignancy associated HLH is primarily reported in T/NK (natural killer)-cell malignancies but also in B-cell neoplasms and other types of cancer. HLH has also been reported in rare cases as a highly fatal and difficult to diagnose complication of stem cell transplantation (SCT). In this paper, we present the case of a young male patient who underwent autologous SCT as consolidation therapy for a T/NK-cell lymphoma, complicated with graft failure due to HLH. The patient was successfully treated with corticosteroids, Etoposide, Cyclosporine and immunoglobulins. As a particularity, he developed a second B-cell neoplasia a few months after SCT.

Corresponding author: Andrei Colita, MD, PhD; e-mail: andreicolita@yahoo.com

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30. Partial abnormal drainage of superior and inferior caval veins into the left atrium: two case reports

Massimo Chessa, Mario Carminati, Eliza-Elena Cinteza, Gianfranco Butera, Luca Giugno, Carmelo Arcidiacono, Luciane Piazza, Nicolae Cristian Bulescu, Giuseppe Pome, Alessandro Frigiola, Alessandro Giamberti

Abnormal connection of the right superior caval vein to the left atrium is an uncommon systemic vein drainage anomaly, with only a few cases reported among congenital heart disease (CHD), around 20 cases published in the medical literature. The inferior vena cava connection with the left atrium, also very rare, can appear directly or in heterotaxy. Clinical suspicion arises due to the presence of cyanosis in the absence of other specific clinical signs (without other associated CHD). We present the cases of two children with abnormal superior and inferior systemic venous return. The first case is an abnormal connection of right superior vena cava to the left atrium associated with persistent left superior vena cava draining into the right atrium through the coronary sinus. The second case is an interruption of the inferior vena cava with hemiazygos continuation, drained into the left superior vena cava, which drained into the left atrium. The diagnosis was imagistic - echocardiography and angiography. Surgical treatment solutions vary from one case to another, usually following anatomic correction. Hypoxia accompanied by cyanosis must bring into question the pathology of systemic venous drainage anomaly, after other common causes have been excluded. Surgery is indicated in all cases due to the risk associated with the presence of right-to-left shunt.

Corresponding author: Eliza-Elena Cinteza, MD, PhD; e-mail: elizacinteza@yahoo.com

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31. A 61-year-old woman with adult T-cell leukemia/lymphoma

Vitorino Modesto Dos Santos, Eduardo Flavio Oliveira Ribeiro, Priscilla Souza De Faria, Isabella Augusta Barros, Marcelo Martins Oliveira

Adult T-cell leukemia/lymphoma (ATL) is caused by human T-cell lymphotropic virus type-1 (HTLV-1) infection. Classification of ATL includes acute, chronic, lymphomatous and smoldering, and main features are hypercalcemia, organomegaly, bone, brain, lung, and skin changes. Elevated mortality rates of ATL may be due to the advanced age at diagnosis, because this malignancy can evolve unsuspected for decades before the first clinical manifestations. Palliative therapy, chemotherapy and stem cell transplantation are often utilized, but response to treatment is poor. The patient herein reported presented diffuse abdominal pain with duration of eight months in addition to ascites. The diagnosis of the acute leukemia type of ATL was done with base on clinical, laboratory and imaging findings. Gastrointestinal symptoms and ascites are uncommon first manifestations of ATL, and pose challenging diagnosis.

Corresponding author: Vitorino Modesto dos Santos, Professor, MD, PhD; e-mail: vitorinomodesto@gmail.com

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32. The interdisciplinary approach of an aggressive giant cell tumor of bone complicated with a fracture of the distal femur

Iulian Daniel Vilcioiu, Dragos-George Zamfirescu, Ioan Cristescu, Andrei Ursache, Serban-Arghir Popescu, Cosmin Antoniu Creanga, Ioan Lascar

Giant cell tumor of bone (GCTB) represents one of the commonest bone tumors encountered by an orthopedic surgeon. The giant-cell tumor is generally classified as benign but the fast growing rhythm and the aggressive soft-tissue invasion may in some cases demonstrate a malign potential of the tumor. We present the case of an aggressive giant cell tumor in a young patient that was first diagnosed in our emergency department with a fracture of the distal femur after a low energy trauma. With further examinations, we discovered that the tumor was invading the both femoral condyles and was vascularized by three major arterial pedicles. The onset of his problems was the femoral fracture and the changes on the major vessels, muscles and nerves. After an interdisciplinary approach of the patient and a meticulous preoperative planning, we decided to make an extensive total resection of the tumor followed by a complex reconstruction surgery for the bone. A very stable fixation of a vascularized graft allowed the bone to heal even if the surrounded soft-tissue was almost completely invaded by the tumor and removed during the excision. The follow-up of this case demonstrated that using an interdisciplinary approach of the patient with the Plastic Surgery team, we manage to remove the tumor within oncological limits and achieved bone healing with good stability of the distal femur.

Corresponding author: Dragos-George Zamfirescu, MD, PhD; e-mail: dragoszamfirescu@gmail.com

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33. A very rare association between giant right atrial myxoma and patent foramen ovale. Extracellular matrix and morphological aspects: a case report

Adrian Molnar, Svetlana Encica, Diana Maria Sacui, Ioan Muresan, Aurelian-Catalin Trifan

We report a case of sporadic giant cardiac myxoma with a rare localization in the right atrium, operated in our Service, in a 73-year-old female patient who also presented a patent foramen ovale and a history of ischemic stroke in the year prior to current admission. Intra-operatively, the tumor had a very friable, gelatinous aspect, with a high potential for embolization due to its reduced consistency. The present paper refers to clinical, histochemical and immunohistochemical particularities, as well as to macroscopic and microscopic characteristics of the cardiac myxoma, emphasizing the extracellular matrix aspects, and without leaving out the cellular components of this rare tumor, with possible inference in the management of this disease. The authors present their own observations related to the data from the literature. Also, there are some particularities of the case which justify the current presentation.

Corresponding author: Adrian Molnar, Assistant Professor, MD, PhD; e-mail: adimolnar45@yahoo.com

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34. Clinical and color Doppler imaging features of one patient with occult giant cell arteritis presenting arteritic anterior ischemic optic neuropathy

Dragos Catalin Jianu, Silviana Nina Jianu, Ligia Petrica, Andrei Gheorghe Marius Motoc, Traian Flavius Dan, Dorela Codruta Lazureanu, Mihnea Munteanu

Anterior ischemic optic neuropathies (AIONs) represent a segmental infarction of the optic nerve head (ONH) supplied by the posterior ciliary arteries (PCAs). Blood supply blockage can occur with or without arterial inflammation. For this reason, there are two types of AIONs: non-arteritic (NA-AION), and arteritic (A-AION), the latter is almost invariably due to giant cell arteritis (GCA). GCA is a primary vasculitis that predominantly affects extracranial medium-sized arteries, particularly the branches of the external carotid arteries (including superficial temporal arteries - TAs). One patient with clinical suspicion of acute left AION was examined at admission following a complex protocol including color Doppler imaging (CDI) of orbital vessels, and color duplex sonography of the TAs and of the carotid arteries. She presented an equivocal combination of an abrupt, painless, and severe vision loss in the left eye, and an atypical diffuse hyperemic left optic disc edema. She had characteristic CDI features for GCA with eye involvement: high resistance index, with absent, or severe diminished blood flow velocities, especially end-diastolic velocities, in all orbital vessels, especially on the left side (A-AION). Typical sonographic feature in temporal arteritis as part of GCA was dark halo sign. On the other hand, she did not present classic clinical or systemic symptoms of GCA: temporal headache, tender TAs, malaise (occult GCA). The left TA biopsy confirmed the diagnosis of GCA. The ultrasound investigations enabled prompt differentiation between NA-AION and A-AION, the later requiring in her case immediate steroid treatment, to prevent further visual loss in the right eye.

Corresponding author: Andrei Gheorghe Marius Motoc, MD, PhD; e-mail: amotoc@umft.ro

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35. Stroma-poor Warthin s tumor with significant oncocytic hyperplasia: case presentation and considerations regarding its histogenesis

Hiroo Kawano, Tokuhiro Kimura, Nami Kikuchi, Aya Ishii, Eiji Ikeda

Although Warthin s tumor is one of the common tumors of the salivary glands, Warthin s tumors with a prominent component of nodular oncocytic hyperplasia reminiscent of oncocytoma are rare. Here we report such a tumor, measuring 3 cm in diameter, found in the parotid gland of an 81-year-old man. Histologically, approximately 70% of the mass was a component of nodular oncocytic proliferation, and the remaining portion was a component of conventional Warthin s tumor. We performed immunohistochemical analysis to explore what factors determined the morphogenesis of the two components in the single mass. Cytokeratin (CK) 5/6-positive tumor cells, which represent basal cells, were aligned in a layer in the conventional Warthin s tumor component, whereas they were localized around blood vessels in the nodular oncocytic hyperplasia component. Immunostaining for CD34 showed that capillaries were sparsely present beneath the bilayered epithelia in the former component, while blood vessels resembling sinusoids separated the trabeculae of the tumor cells in the latter component. Ki-67 labeling index was slightly higher in the latter component. Double immunostaining for CK5/6 and Ki-67 revealed that most of Ki-67-positive proliferating tumor cells were CK5/6-positive, suggesting that CK5/6-positive population contained proliferative progenitor cells of the tumor. These findings imply that the regional difference in the distribution pattern and proliferative activity of CK5/6-positive putative progenitor cells along with the difference in the pattern of vascular network occurred during the tumorigenic process of the tumor and determined one region to become conventional Warthin s tumor morphology and the other to become nodular oncocytic hyperplasia.

Corresponding author: Tokuhiro Kimura, MD; e-mail: tkimura@yamaguchi-u.ac.jp

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36. Renal artery bilateral arteriosclerosis cause of resistant hypertension in hemodialysed patients

Andrei Niculae, Ileana Peride, Adriana Marinescu-Paninopol, Camelia Doina Vrabie, Octav Ginghina, Cristian Radu Jecan, Ovidiu Gabriel Bratu

We present the case of a 57-year-old hemodialysed male patient known with severe hypertension resistant to six classes of hypotensive medication, in maximal doses, correlated with increased ultrafiltration during the hemodialysis session. In this case, bilateral nephrectomy was performed as final treatment option for malignant hypertension, and histopathological examination of both kidneys emphasized arteriosclerosis lesions. The results consisted in better hypertension management, with a reduction in both the number and doses of antihypertensive drugs.

Corresponding author: Ileana Peride, MD, PhD; e-mail: ileana_peride@yahoo.com

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37. Pathological fracture of the femur in a patient with Paget s disease of bone: a case report

Pompiliu Horatiu Petrescu, Dragos Andrei Izvernariu, Catalina Iancu, Gabriel Ovidiu Dinu, Marcel-Mihai Berceanu-Vaduva, Dan Crisan, Mihaela Iacob, Venera Margareta Bucur, Ion Calin Rautia, Ion Radu Prejbeanu, Sorin Dema, Ciprian Constantin Duta

Paget s disease of bone is a benign disease characterized by exaggerated remodeling of the bone matrix after osteoclast-mediated bone destruction. Its etiology is still unknown, despite the fact that it was discovered and described in 1877, but genetic factors and environmental triggers were shown to play their part in the pathogenesis of the disease. The main clinical presentations of the disease are related to bone pain and deformities. Radiological diagnosis is the main detection tool, though many monostotic Paget s disease cases may remain undiagnosed. We present the case of an 81-year-old male patient admitted to the Clinic of Orthopedics, Emergency County Hospital, Timisoara, Romania, with intense pain and deformity of the upper left thigh. Radiological examination performed shows a complete fracture of the upper third diaphysis of the left femur with suggestive signs for Paget s disease of the bone therefore a biopsy was taken and the patient was treated by surgical realignment with favorable evolution. He was discharged 13 days after surgery. The biopsy of the bone revealed extensive bone remodeling with numerous osteoclasts and extensive bone matrix deposition, unevenly stained and unevenly mineralized and reverse cement lines, which are consistent with the diagnosis of Paget s disease of the bone. Histomorphometric analysis show intense matrix deposition with a highly active remodeling process. Computed tomography (CT) scans were performed three years later and show the extension of the disease into the lower half of the left femur.

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

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38. Clinical and histopathological aspects in two cases of ligneous conjunctivitis

Carmen-Luminita Mocanu, Maria-Rodica Manescu, Andreea-Gabriela Deca, Stefania Craitoiu, Sanda Jurja

Ligneous conjunctivitis represents a very rare form of chronic membranous conjunctivitis, with unknown etiology; less than 200 cases have been reported in the literature, most of them in infants and children. After 40 years, this condition appears in exceptional circumstances. We present, in this study, two patients (of 55 and 64 years old) with very severe forms of ligneous conjunctivitis, certified by histopathological examination, one of them being previously diagnosed with Lyell s syndrome. The histological examination in ligneous conjunctivitis is important for diagnostic but also to elucidate the etiopathological context. A discontinued hyperplastic conjunctiva with numerous nuclear abnormalities and marked intra- and inter-cellular edema was characteristic for both cases. The epithelium layer presents large area of extension into the connective tissue, in the form of cysts and gland-like structures, or creating deep epithelial lacunas, with goblet cells. The connective subepithelial tissue presents diffuse inflammatory infiltration, with round cells, especially near vessels. Inside the conjunctival tissue, big hyaline areas with rare cellularity are detected. The amorphous deposits containing fibrillar material are also present. At the level of pseudo-membranes, we recorded a massive exudation of fibrin with an inflammatory cellular infiltration, and large areas containing an amorphous eosinophilic hyaline material. The association of ligneous conjunctivitis with Lyell s syndrome in one of our patients suggests its immuno-allergic etiology.

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

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