ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 59 No. 4, 2018

1. Occupational exposure to urinary bladder carcinogens - risk factors, molecular mechanisms and biomarkers

Marina Ruxandra Otelea, Viorel Jinga, Alexandru Stefan Catalin Rascu, Iancu Emil Plesea, Amelia Nicoleta Petrescu, Luminita Elena Mitrache, Mihai Olteanu, Dan Bondari, Agripina Rascu

Bladder cancer (BC) is one of the most frequent forms of cancer, particularly in Caucasian population. Many environmental factors are recognized as carcinogenic in humans for this form of neoplasia and some of them are related to occupation. In order to illustrate these effects, we have selected several relevant cases with smoking and occupational exposure to carcinogens and their histopathological findings. We reviewed the most important research published in the field of environmental-genomic interaction in relation with the oncogenesis of BC. Three main directions have been identified and described in the article: the environmental factors involved in BC pathogenesis and evolution, the molecular mechanisms involved in cell mitosis control and xenobiotic metabolism related to the qualitative and quantitative exposure and, finally, the possible biomarkers of the tumor evolution. From the genomic and proteomic research, new biomarkers emerged that are in the validation process. Immunohistochemical methods open also new perspectives to the diagnostic algorithms and could serve as prognosis biomarkers.

Corresponding author: Alexandru Stefan Catalin Rascu, Assistant Professor, MD, PhD; e-mail: stefanrascu.sr@gmail.com

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2. Intraoperative assessment of sentinel lymph nodes in early-stage breast cancer

Andrei Ionut Costin, Ion Paun, Flore Varcus, Marian Madalin Racareanu, Ion Lomaca, Adelina-Gabriela Costin, Larisa Iovan, Lucretiu Radu, Gabriela-Marcelina Mihai

The assessment of axillary lymph node (ALN) status provides heavily weighing prognostic indicators in deciding on breast carcinoma treatment. In the 6th and 7th editions of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual are evaluated the nodal metastases based on size and taking into account the number of metastatic cells. According to these Manuals, a positive node is equated to metastasis whose size reaches at least 0.2 mm or amounting to more than 200 tumor cells. The clinical significance and the therapeutic optimum of the presence of a minimal nodal involvement after axillary sentinel lymph nodes (SLNs) biopsy remain controversial. The need for further axillary treatment (ALN dissection or axillary radiation) in clinical N0 patients with early-stage breast carcinoma and SLNs metastases remains unclear. In all likelihood, the delivery of the regular adjuvant treatment in association with systemic treatment and radiation therapy results in survival rates similar to axillary treatment completion. This review also presents several assessment methods related to the SLNs at the surgical stage, such as cytological, histological, immunohistochemical and molecular diagnostic techniques, evaluating the advantages and disadvantages of each of them. More studies including larger groups of breast patients are needed to confirm which of them is the most reliable method for the evaluation of the SLNs.

Corresponding author: Ion Paun, Associate Professor, MD, PhD; e-mail: dripaun@gmail.com

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3. Acute limb ischemia in neonates: etiology and morphological findings - short literature review

Simona Cerbu, Florin Birsasteanu, Elena Rodica Heredea, Daniela Iacob, Emil Radu Iacob, Maria Corina Stanciulescu, Eugen Sorin Boia

The acute limb ischemia (ALI) in neonates is a rare phenomenon, but with serious consequences if undiagnosed or untreated. The purpose of this review is to briefly present the etiology of ALI and morphological findings in correlation with specific causes. Etiology can be classified into two main groups: prenatal (in utero compression, thrombosis and embolism) and postnatal (iatrogenic, thromboembolism and vascular malformations). The most common cause of ALI is catheter-related thrombosis (almost 90% of thrombosis cases are associated with catheter use), but other rare causes like vascular malformations should not be overlooked. Ultrasound represents a non-invasive, inexpensive and widely available imaging technique, which provides sufficient information to evaluate the situation and establish proper therapeutic strategies. Morphological tests do not represent the standard diagnostic procedure in ALI, but they can provide useful information. The findings depend on the etiology: intraluminal thrombi, vascular changes, placental pathological modifications. Every morphological result must be correlated with the clinical picture and imagistic findings. In conclusion, ALI in neonates is a rare condition, usually associated with catheter use in intensive care unit setting, with multiple risk factors and conditions that increase the risk of occurrence.

Corresponding author: Emil Radu Iacob, Lecturer, MD, PhD; e-mails: radueiacob@umft.ro, radueiacob@yahoo.com; Daniela Iacob, Associate Professor, MD, PhD; e-mail: danielariacob@yahoo.com

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4. A review of the influence the anxiety exerts on human life

Dan Nechita, Florina Nechita, Raluca Motorga

Our intention has been to review the literature addressing the anxiety phenomenon from as many points of view as possible. By searching in PubMed and Web of Science and by using multiple filters, we have included, of the over 1800 results, 93 studies with the aim of covering more aspects of life anxiety exerts its influence upon. We have discussed the connection between anxiety and physiological and psychological functioning, or its connection with the areas of family, religion, social life and behavior, as well as the cultural side, childhood, pregnancy and many others.

Corresponding author: Florina Nechita, Lecturer, PhD; e-mail: florina.nechita@yahoo.com

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5. Determination of VEGFR-2 (KDR) -604A>G polymorphism in recurrent pregnancy loss

Lidia Boldeanu, Cristian Adrian Silosi, Vlad Padureanu, Anda Lorena Dijmarescu, Maria Magdalena Manolea, Maria Carmen Tabacu, Mihail Virgil Boldeanu, Mircea Vasile Popescu-Driga, Ioan Sabin Poenariu, Rodica Padureanu, Liliana Victoria Novac, Marius Bogdan Novac

Background: Placental angiogenesis and vascular adaptation during pregnancy, along with diminished placental trophoblastic vascular endothelial growth factor immunoreactivity, play an important role in the early stages of human pregnancy, being possible causes of recurrent pregnancy loss (RPL). Aims: Our focus was directed towards investigating a possible association between vascular endothelial growth factor receptor-2 (kinase insert domain receptor) VEGFR-2 (KDR) -604A>G (rs 2071559) gene polymorphism and RPL in the study area of Dolj County, Romania. Patients, Materials and Methods: In this study, 169 women, diagnosed with RPL, were included. They were hospitalized in the Clinics of Obstetrics and Gynecology, Filantropia Municipal Hospital, Craiova, during the following period: October 2009-October 2016. The control group consisted of 145 women. All subjects were genotyped by means of allelic discrimination TaqMan polymerase chain reaction assay with specific probes. Results: No statistically significant difference was observed between the RPL patients and the control group, when one genotype was compared to another [in a dominant model, -604 AG+GG vs. AA: odds ratio (OR) 1.71, 95% confidence interval (CI) 0.99-2.96, p=0.051]. While studying the overall risk of RPL by the genotype frequencies of KDR polymorphism between controls and RPL patients, which were stratified according to the number of consecutive pregnancy losses (PLs), the chi-square test showed a significant association between the presence of this polymorphism and the increased risk observed in patients with four or more consecutive PLs, to develop RPL (in a dominant model - G allele carriers, KDR -604 AG+GG vs. AA: OR 1.91, 95% CI 1.03-3.52, p=0.037). These results prove that G allele carriers have an increased risk of RPL about 1.91-fold higher than those with the AA genotype do. Although our results bear limited statistical significance, the study nonetheless represents a step forward in the evaluation of recurrent abortion, which has not yet been explored sufficiently. Conclusions: VEGFR-2 (KDR) polymorphism does not influence RPL susceptibility in the study area of Dolj County, Romania. Therefore, further studies, which include a larger sample size, are required in order to clarify the role of KDR polymorphism in RPL.

Corresponding author: Mihail Virgil Boldeanu, Lecturer, MD, PhD; e-mails: laborator.imunologie@umfcv.ro, boldeanumihailvirgil@yahoo.com

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6. The role of glomerular morphometric features in pediatric podocytopathies - a single center study

Diana Derewicz, Valentin Tiberiu Moldovan, Leila Ali, Roxana Taras, Cosmin Florescu, Mihaela Balgradean, Maria Sajin

Podocytopathies represent a well-studied subgroup of glomerulopathies, being characterized by proteinuria due to damage or dysfunction of podocytes. Glomerular size in podocytopathies has been studied in different population, but only a few studies take in consideration the pediatric population. There are different methods to assess the glomerular size, but most of the studies report the maximal profile area as being the most accurate one. The aim of this study is to determine the range values of glomeruli in pediatric population with glomerulopathies and to establish a correlation between the measured size and several laboratory features. The patients that undergo renal biopsy in the Department of Nephrology, Maria Sklodowska Curie Clinical Emergency Hospital for Children, Bucharest, Romania, were divided into two groups: control vs. affected/patient group. The control group included children that require renal biopsy for renal impairments other than high-range proteinuria (most of them recurrent microscopic asymptomatic hematuria), while the affected group had nephrotic-range proteinuria. Thirty patients were selected to be part of the control group and 30 patients in the affected group. In control group, the mean value diameter was 166.23+/-13.04 micro-m, and the area of the glomerulus had a mean value of 19 126.86+/-3070.83 micro-m2. In the affected group, we obtained the following results: the mean value diameter was 192.42+/-28.15 micro-m, while the glomerular cross-sectional area had a mean value of 23 535.55+/-6456.57 micro-m2. Using the linear regression, we concluded that all the cases with increased-size glomeruli had more urinary protein loss compared with the ones that had small-size glomeruli and low-range proteinuria.

Corresponding author: Diana Derewicz, MD, PhD Student; e-mail: diana_costache195@yahoo.com

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7. A novel combination of double primary malignancies: penile carcinoma and glioblastoma. A series of two cases

Lucian Eva, Bogdan Ionut Dobrovat, Danisia Haba, Georgeta Munteanu, Lucia Indrei, Nicoleta Dumitrescu, Ionela-Lacramioara Serban

Aim: Penile squamous cell carcinoma (pSCC) and glioblastoma (GB) are rare malignant tumors that develop especially in the elderly. The aim of our paper is to present two patients diagnosed and treated for a cerebral GB developed after a prior pSCC and to discuss the possible mechanism of their association. Patients, Materials, and Methods: The medical records of 632 patients admitted for a GB in the Department of Neurosurgery, Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iasi, Romania, between April 2010 and April 2018, were retrospectively searched for those having a prior histological proven cancer. The review found only two patients (0.31% of all cases with GB) and their demographics, clinical presentation, medical history, treatment and pathological diagnosis were reviewed and discussed. Results: Both patients were 65-year-old on their admission in the Department of Neurosurgery. Their prior penile tumors were both located at the penis glans. In both cases, the histopathological exam revealed a penile keratinized squamous cell carcinoma stage T1aN0M0 at the moment of their first urological diagnosis. At the time of the neurosurgical evaluation, brain radiological investigations demonstrated right frontal cystic neoformation in the first case, and a right frontal-parietal solid, expansive lesion for the second patient. The patients underwent subtotal surgical excision of their brain masses. The histopathological exam revealed in both cases a World Health Organization (WHO) grade IV GB. Conclusions: This is the first clinical report of a new association between pSCC and subsequent development of GB in a series of two patients. Both our patients developed a prior pSCC without any lymph node and distant metastasis at their first diagnosis and this situation reinforces the idea that this type of cancer has a good prognosis and that the patient can develop a second cancer during his post-penectomy life, probably due to a genetic predisposition, post-therapeutic effects, life style factors (smoke effects), sporadic association, or due to the common embryological origin of the nervous and skin tissues.

Corresponding author: Lucian Eva, MD, PhD; e-mail: elucian73@yahoo.com; Bogdan Ionut Dobrovat, MD, PhD; e-mail: bogdan.dobrovat@yahoo.com

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8. Intestinal fatty acid-binding protein, as a marker of anastomotic leakage after colonic resection in rats

Gabriel Alexandru Popescu, Ioan Jung, Bogdan Andrei Cordos, Leonard Azamfirei, Adina Hutanu, Simona Gurzu

Aim: The aim of this experimental study was to determine if the type of termino-terminal anastomosis of the colon affect the process of healing of the intestinal mucosa and if the severity of the anastomotic leakage (AL) can be predicted based on the circulating level of intestinal fatty acid-binding protein (I-FABP). Materials and Methods: In 18 healthy Wistar rats, two types of open colon resection with termino-terminal anastomosis were performed: group A (n=9) - without inversing the vascularization and group B (n=9) - with inversing the vascularization. To assess the intestinal barrier function, circulating level of I-FABP was measured pre- and post-operatively. I-FABP tissue expression was immunohistochemically assessed in the anastomotic and perianastomotic colonic mucosa. The rats were sacrificed at three, five, and seven days after surgery. Results: In both groups, the post-operative serum level of I-FABP increased 3-4 times at 3-5 days and seven times in the seventh post-operative day. In the six cases that showed AL, the increased level was significantly higher: seven times at three days (n=2) or five days (n=2) and 30 times at seven days (n=2). The I-FABP epithelial expression was lost in all cases from group B (as result of prolonged ischemia) and in cases with AL from group A. The I-FABP was translocated in the intraglandular mucus. Conclusions: The post-operative level of I-FABP can be appreciated based on the pre-operative value only. A 7-8 increased value in first five days might indicate a risk of AL. After seven days, a seven times increased value is an indicator of a proper healing process but an increasing amount higher that 30 times might predict risk for AL, fistula, peritonitis and septic shock. The risk of AL does not depend on the anastomotic method, although the level of ischemia is higher in anastomoses that involve vascular damage.

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

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9. Hand enchondroma - complete evaluation and rehabilitation

Magdalena Rodica Traistaru, Diana Kamal, Raluca Niculina Ciurea, Paraschiva Postolache, Dragos Ovidiu Alexandru, Otilia Constantina Rogoveanu, Kamal Constantin Kamal

Enchondroma, the most frequently reported primary tumor in the long bones of the hand, is a common benign cartilaginous tumor, defined more exactly as a benign mature hyaline cartilaginous tumor that is located into the medullar space of the tubular bones. Between 2012 and 2018, we performed an observational study on six patients (two males and four females), aged 16 to 49 years old (mean 29.5 years), who were diagnosed during routine physical examinations with isolated enchondroma in their hand. The tumor was more frequently located in their proximal phalanges (four patients), while two patients had middle phalange tumors. The most common digit involved was the little finger (five patients), followed by the ring finger (one patient). The symptoms, which prompted surgical interventions, were: enlargement without fracture (two patients), pain or limitation of mobility (four patients), pain without pathological fracture (six patients). Studied patients were completely assessed before the treatment program (surgical intervention and rehabilitation program). The measured parameters and scales used were Visual Analogue Scale (VAS), Health Assessment Questionnaire (HAQ) scale for functional status and histological exam. For both VAS and HAQ, we observed a statistically significant difference between the initial and final evaluations, with p=0.03 and p=0.035, respectively. Histological assessment and differential diagnosis are essential for the post-surgical treatment and rehabilitation program.

Corresponding author: Dragos Ovidiu Alexandru, Associate Professor, MD, PhD, MSc; e-mail: dragosado@yahoo.com; Diana Kamal, MD, PhD, MSc; e-mail: dianakamal84@gmail.com

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10. NBI-assisted digital flexible ureteroscopy in transitional renal cell carcinoma - an evidence-based assessment through the looking glass of the pathological analysis

Valentin Florin Iordache, Petrisor Aurelian Geavlete, Dragos Adrian Georgescu, Cosmin Victor Ene, Maria Alexandra Paunescu, Andrei Niculae, Ileana Peride, Tiberiu Paul Neagu, Catalin Andrei Bulai, Georgiana Xenia Balan, Bogdan Florin Geavlete, Ioan Lascar

Introduction: Digital flexible ureteroscopy (FURS) increasingly became a routine diagnostic procedure in upper urinary tract transitional cell carcinoma (UUT-TCC). Identifying elements that may suggest the malignant nature of a lesion and obtaining biopsy specimens sufficient for a reliable pathological analysis remain difficult challenges. Narrow-band imaging (NBI) technology appears to provide a more accurate observation of the upper tract urothelium. Patients, Materials and Methods: During this prospective analysis, white light (WL) and NBI-assisted digital FURS were performed in 87 consecutive patients admitted for primary suspicion of UUT-TCC. The endoscopic technique comprised digital WL FURS, followed by the NBI assessment of the renal collecting system mucosa. All suspicious areas of the pyelocaliceal urothelium were biopsied using the grasping forceps, separately for WL and NBI findings. Results: A total of 113 UUT-TCC tumors (104 pTa and nine carcinoma in situ - CIS) were confirmed by pathology in 62 patients. The patients detection rate was significantly improved in NBI mode when compared to standard FURS (98.4% versus 91.9%, respectively), due to cases either exclusively diagnosed with UUT-TCC (8.1%) or presenting additional urothelial tumors (12.9%). Overall, 13 pTa and two CIS lesions were solely observed in NBI, which was on the other hand characterized by a significantly increased proportion of unnecessary biopsies (NBI versus WL rate of false-positive results - 17.5% versus 10.1%, respectively). Conclusions: As additional tool for the standard WL evaluation of the pyelocaliceal system urothelium, NBI-guided biopsies were emphasized as providing a significant diagnostic improvement during digital FURS.

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

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11. Looking beyond gut inflammation in inflammatory bowel disease

Anca Cardoneanu, Cristina Cijevschi Prelipcean, Mihai Danciu, Catalina Mihai, Mihaela Dranga, Otilia Gavrilescu, Elena Rezus

Patients diagnosed with inflammatory bowel disease (IBD) often develop one or more extraintestinal manifestations (EIM). We performed a prospective study that included 517 patients with IBD (Crohn s disease - CD, ulcerative colitis - UC or undifferentiated colitis - CN) diagnosed between 1975 and 2016 in the Northeastern region of Romania. The patients were extracted from the national database (IBD Prospect). UC cases predominated compared to CD cases (n=368 vs. n=135). Only 10 patients were diagnosed with CN. In the study group, 51 cases with IBD and EIM were identified, having a prevalence of 9.9%. Musculoskeletal manifestations were the most common EIM. Peripheral involvement - arthritis (n=26, 68.42%) predominated, followed by axial damage - sacroiliitis/ankylosing spondylitis (SI/AS) (n=12, 31.58%) (p=0.001). Patients with CD had a 3.48-fold greater risk of developing joint manifestations [p<0.001, odds ratio (OR)=3.478, 95% confidence interval (CI) 1.779-6.801]. In both CD and UC patients, arthritis cases were the most frequent observed (68.42% vs. 31.58%). Patients with CD had a 5-fold higher risk of developing arthritis (p<0.001, OR=5.009, 95% CI 2.21-11.34). Neither CD, nor UC patients, had a confirmed risk of developing SI/AS (p=0.468, OR=1.565, 95% CI 0.463-5.293 for CD) (p=0.586, OR=0.714, 95% CI 0.211-2.413 for UC). Cases of arthritis and CD (n=16) mainly correlated with the colonic localization of inflammation (n=7, p=0.723) followed by ileo-colonic form of CD (n=7, p=0.321). Patients with arthritis and UC (n=10) initially correlated with pancolitis (n=5, p=0.072, OR=3.023, 95% CI 0.855-10.69) then with proctitis (n=3, p=0.392) and left-sided colitis (n=2, p=0.024, OR=0.196, 95% CI 0.041-0.938).

Corresponding author: Catalina Mihai, Lecturer, MD, PhD; e-mail: catalinamihai@yahoo.com; Mihai Danciu, Professor, MD, PhD; e-mail: mihai.danciu@umfiasi.ro

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12. Evaluation of antioxidant capacity and clinical assessment of patients with chronic periodontitis treated with non-surgical periodontal therapy and adjunctive systemic antibiotherapy

Simina Boia, Stefan-Ioan Stratul, Marius Boariu, Sorin Ursoniu, Smaranda Laura Gotia, Eugen Radu Boia, Claudia Borza

This study aims to evaluate the oxidative stress changes in patients with chronic periodontitis (CP) undergoing non-surgical periodontal therapy alone, compared with non-surgical periodontal therapy with adjunctive systemic antibiotic therapy. Sixteen patients with CP, randomly assigned into two equal groups, were treated either with scaling and root planing (SRP) + Amoxicillin + Metronidazole, each 500 mg, three times daily, for seven days (test group), or with SRP + placebo for seven days (control group). Venous blood and unstimulated saliva samples were collected. Non-surgical periodontal therapy was performed simultaneously with antibiotics administration. Oxidative stress balance was evaluated by measuring derivatives of reactive oxygen metabolites (d-ROMs) and the biological antioxidant potential (BAP) in plasma. After the microscopic evaluation of the pathological aspect of the epithelial cells (ECs), their number, viability and the presence of C-reactive protein (CRP) were reevaluated from saliva at seven days, while reduced glutathione (GSH) level, d-ROMs and BAP at three months. Wilcoxon and Kruskal-Wallis rank-tests were used for statistics. At three months, statistical significant reductions of mean periodontal pocket depth (PPD) and clinical attachment level (CAL) gains (both p=0.01) were found in test group. Full-mouth plaque score (FMPS) decreased statistically significant in control group (p=0.02), d-ROMs decreased statistically significant in test group (mean difference 116.24+/-107.6 U CARR, p=0.01). Mean GSH, BAP level, number of ECs, their viability and CRP were statistically non-significant. In test group patients, oxidative stress status changed from a very high level to a medium one, suggesting that adjunctive use of antibiotics could have contributed to the reduction of reactive oxygen metabolites, along with significant clinical improvements.

Corresponding author: Marius Boariu, Lecturer, DMD, PhD; e-mail: boarium@yahoo.com

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13. Immunoexpression of p53 and COX-2 in basal cell carcinoma

Andreea Oana Enache, Alex Emilian Stepan, Claudiu Margaritescu, Virgil Patrascu, Raluca Niculina Ciurea, Cristiana Eugenia Simionescu, Adrian Camen

Basal cell carcinoma (BCC) is a variety of cutaneous carcinoma associated with an excellent prognosis because it rarely metastasizes, but it can cause significant local destruction and morbidity if surgical excision is not made. In this study, we examined the immunohistochemical expression of p53 and cyclooxygenase-2 (COX-2) in 51 BCCs, nodular and infiltrative subtypes, with various Clark levels. The immunoexpression of p53 was identified in 74.5% BCC cases and COX-2 reactions in 88.2% of cases. The scores of p53 reactions revealed significant differences depending on Clark level and borderline significance with tumor type, the high positive scores being associated to infiltrative tumors and high Clark level. No differences were revealed between COX-2 scores with both Clark level and tumor type. The analysis of the percentage values of p53 and COX-2 indicated a positive linear correlation. The positivity of p53 and COX-2 in a large proportion of BCCs, regardless of histological type and of depth of invasion, supports the two markers involvement in tumor progression.

Corresponding author: Alex Emilian Stepan, Associate Professor, MD, PhD; e-mail: astepan76@yahoo.com; Cristiana Eugenia Simionescu, Professor, MD, PhD; e-mail: csimionescu2004@yahoo.com

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14. The process of liver fibrosis in chronic hepatitis C - histological and immunohistochemical study

Nicoleta Laura Popescu, Octavian Ion Predescu, Oana Badea, Ionica Pirici, Carmen Pantis, Cristina Jana Busuioc, Bogdan-Virgil Cotoi, Laurentiu Mogoanta

Liver fibrosis is one of the most serious histopathological (HP) lesions that, together with the inflammatory process and the hepatocyte lesions, determine the change of the liver architecture, having as a clinical result the onset of liver failure phenomena. Hepatitis C virus represents one of the most frequent conditions leading to the onset of liver fibrosis and favors the progression of the disease towards hepatocellular carcinoma. We evaluated the HP and immunohistochemical (IHC) aspects on fragments of liver biopsies taken from 104 patients diagnosed with chronic hepatitis C and altered capacity of work. In our study, we observed a growth of the portal (Kiernan) spaces by the presence of a chronic inflammatory infiltrate, the presence of collagen fibers and conjunctive matrix. The density and dimensions of collagen fibers were correlated with the severity of the liver disease, in the severe forms being highlighted porto-portal and porto-central fibrous bridges. The IHC examinations highlighted the change of the phenotype of perisinusoidal dendritic cells, the growth of the myofibroblast cells in the portal spaces, the growth of the macrophage number in the inflammatory infiltrate and of the Kupffer cells in the liver parenchyma.

Corresponding author: Cristina Jana Busuioc, Associate Professor, MD, PhD; e-mail: dr_cristinab@yahoo.com; Bogdan-Virgil Cotoi, Lecturer, MD, PhD; e-mail: bogdan230376@yahoo.ro

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15. UPA effects on endometrium - what is the significance?

Liana Ples, Romina-Marina Sima, Delia Carp, Cosmin Florescu, Mihai Cornel Traian Dimitriu, Cringu Antoniu Ionescu

Introduction: Selective progesterone receptor modulators (SPRMs), such as Mifepristone, Asoprisnil, Ulipristal acetate (UPA) and Vilaprisan, were tested for their antiproliferative effects on uterine fibroids. In Romania, despite the UPA availability, physicians remained reserved on the lack of experience and concerns about the safety of the drug on endometrium. Patients, Materials and Methods: We performed an observational study on premenopausal women with symptomatic uterine fibroids. The patients received UPA in doses of 5 mg for 12-13 weeks. The fibroids dimensions and endometrium thickness were recorded at before and after the treatment. The pathological samples were assessed by two pathologists, and they recorded progesterone receptor modulator associated endometrial changes (PAEC) as extensive PAEC (EPAEC), minimally PAEC (MPAEC), absent PAEC (APAEC) and Ki67 immunoexpression in endometrium. Results: A number of 57 women were introduced in our study and we had a dropout of one patient. The fibroid dimensions and endometrial thickness decreased after UPA. The pathological exam of the endometrium revealed: APAEC in 26.8% of cases, MPAEC in 60.7% of cases and EPAEC in 12.5% of cases. EPAEC were more frequent in patients with larger fibroids. PAEC had a strong correlation with Ki67 index (p<=0.01). PAEC were more frequent in older women (p<=0.01). Ki67 had a higher expression in EPAEC - mean: 69% (range: 63-75%), standard deviation (SD): 3.95. Conclusions: UPA treatment decreased fibroids dimension and improved patients symptoms in our study. EPAEC was associated with abundant Ki67 antigen. UPA administration for three months is a safe method without endometrial atypia but longer protocols require extended studies about the proliferative potential of the endometrium.

Corresponding author: Romina-Marina Sima, Assistant Professor, MD, PhD; e-mail: romina.sima@yahoo.es

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16. Clinical, morphological and immunohistochemical survey in different types of endometriosis

Anca-Maria Istrate-Ofiteru, Daniel Pirici, Mihaela Niculescu, Costin Berceanu, Sabina Berceanu, Nicoleta-Loredana Voicu, Georgeta-Diana Piringa, Gabriela-Camelia Rosu, Larisa Iovan, Razvan Grigoras Capitanescu, Damian Ditescu, Anca Sava, Laurentiu Mogoanta, Adrian Neacsu

Endometriosis is a benign pathology, commonly found in women at reproductive age. It is represented by the ectopic presence of the endometrial glandular epithelium in several tissues and organs. This ectopically located tissue can display premalignant or even malignant changes under the influence of certain factors that affect cell structure, function and proliferation. Our study includes a total of 28 patients, with endometriosis of different localizations: ovarian or pelvic endometriosis, adenomyosis or endometriosis of the abdominal wall. We performed a clinical and statistical analysis upon the collected clinical and laboratory data, together with the results obtained by using classical histological and immunohistochemical (IHC) profiling. The classical staining revealed the existence of the ectopic glandular epithelium, while the IHC reactions obtained with the anti-cytokeratin (CK) 7/anti-CK20, anti-estrogen receptor alpha (ERalpha)/anti-progesterone receptor (PR) antibodies, ascertained that these tissues were of endometrial origin. The environmental, hormonal or inflammatory factors influence these areas, so that the ER/PR scores may be modified, the cellular proliferation might be increased (Ki67+ marker), the anti-apoptotic B-cell lymphoma 2 (BCL2) protein expression and phosphatase and tensin homolog (PTEN) may also be modified. Moreover, tumor protein 53 (p53) was positive in cases with atypia, density of inflammatory cells clearly increased compared to the adjacent normal endometrium, respectively with cluster of differentiation (CD) 3+, CD20+, CD68+, CD79alpha+, and tryptase+ cells, all of which may influence the cellular structure, histological architecture of the surrounding microenvironment and cause premalignant or even malignant changes in endometriosis outbreaks.

Corresponding author: Costin Berceanu, Associate Professor, MD, PhD; e-mail: dr_berceanu@yahoo.com; Anca Sava, Professor, MD, PhD; e-mail: dr.anca.sava.68@gmail.com

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17. Diagnosis, morphopathological profile and treatment of mucinous cystadenoma of the pancreas - a single center experience

Bogdan Mihail Dorobantu, Emil Matei, Vlad Herlea, Mirela Boros, Beatrice Tivadar, Silviu Horia Ciurea

Aim: Pancreatic mucinous cystadenoma (MCA) occurs almost exclusively in perimenopausal women and represents between 10% and 45% of cystic neoplasm of the pancreas, being considered a premalignant lesion. Materials and Methods: From 1983 to 2017, 31 patients underwent surgery for MCA of the pancreas in our Center. The median age was 47 years (range 17-81 years). All data were obtained retrospectively. Results: The female/male gender ratio was 14.5/1. Most of the patients (90.3%) were symptomatic. The most common clinical manifestation was non-specific abdominal pain (58.06%), followed by fatigue and vomiting. The median cyst size was 7 cm, with a range between 2 cm and 15 cm. There were 35 procedures in 31 patients (in four patients the resection was preceded by a drainage procedure). From the 28 resections, most of them (89.28%) were performed by an open approach; a minimal invasive approach was used in three patients (robotic - two; laparoscopic - one). Most of the resections (82.14%) were distal pancreatectomies. In all cases, the final diagnosis was based on histological examination that revealed columnar epithelium and ovarian-type stroma. Postoperative complications occurred in 10 (34.48%) patients. Postoperative mortality was 3.44% (one patient) by septic shock secondary to acute postoperative pancreatitis. Conclusions: MCAs represent a rare pancreatic pathology with challenging diagnostic and therapeutic implications. Multi-detector computed tomography (MDCT) scan, endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) are useful in the differential diagnosis with other pancreatic fluid collections and treatment. Oncological surgical resections are recommended. Histopathological examination establishes the final diagnosis. The most common postoperative complication is pancreatic fistula.

Corresponding author: Emil Matei, MD; e-mail: emmatei@gmail.com

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18. Mesenchymal stem cells derived from adipose tissue and Ishikawa cells co-culture highlight the role of adiponectin in endometrial cancer pathogenesis

Razvan Ciortea, Sergiu Susman, Andrei Mihai Malutan, Costin Berceanu, Radu Florin Mocan-Hognogi, Carmen Elena Bucuri, Olga Soritau, Ioana Neagoe, Dan Mihu

Visceral obesity is a risk factor for endometrial cancer (EC). Visceral adipose tissue secretes over 50 inflammatory cytokines that can act centrally to regulate different physiological processes of the body but also remotely involved in communicating messages from the adipose tissue to other target tissues. The purpose of this study is to demonstrate the effect of in vitro adipose mesenchymal stem cells (MSCs) on endometrial tumor cells. Materials and Methods: Adipose-derived stem cells (ASCs) were isolated from normal subcutaneous (SC) and omentum adipose tissue from one woman without any other pathologies associated during a Fallopian tube ligature intervention. From one patient with EC was also harvested both SC and omentum adipose tissue. Ishikawa cells were cultured in ASCs conditioned medium. Study outcomes included detection of adipokines in cell culture supernatants and cell lysates by the enzyme-linked immunosorbent assay (ELISA). Results: Our results indicate that cells from the EC patient s fat tissues migrated during the first days of cultivation and had a high proliferation rate. Ishikawa cells grown in MSCs co-culture showed lower absolute values of adiponectin than the cells cultured individually, having a pro-tumoral effect. The differences were statistically significant compared to Ishikawa cells in monoculture. In supernatants of MSCs, an increase in adiponectin s values in MSCs from SC adipose tissue of the patient with EC (SC cMSCs) was observed in co-culture as compared to monocellular control culture. Conclusions: Our data confirm the hypothesis that ASCs are an important source of intracellular adiponectin, which increase the EC cell proliferation.

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

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19. Clinical, surgical and morphological assessment of the pyeloureteral syndrome

Gheorghe Adrian Bumbu, Mihail-Claudius Berechet, Karim Nacer, Gheorghe Bumbu, Octavian Adrian Maghiar, Ovidiu Gabriel Bratu, Razvan Marius Vicas, Ovidiu Tica, Bogdan Andrei Bumbu

Obstruction of the pyeloureteral junction (PUJ) is by far the most common cause of hydronephrosis in children, with an incidence of one in 1000-2000 newborns. Also, the obstruction of the PUJ is the most common cause of prenatal hydronephrosis, accounting for 80% of the cases. The aim of this study is to observe and discuss first the efficacy of described surgery procedures and second the microscopic modifications of the PUJ (abnormalities of smooth muscle tissue, inflammation and fibrosis). One hundred and eleven children with a diverse urological pathology with an average age of 11.57 years were operated between 2011 and 2015 in Urology Clinic of Oradea, Romania. Of these, 20 children (11 boys and nine girls) with congenital hydronephrosis by junction syndrome required surgical correction. The surgical techniques used were Anderson-Hynes dismembered pyeloplasty, non-dismembered Scardino procedure and the Hellstrom procedure. Operator interventions were performed by subcostal lombotomy with or without partial XII rib resection. The average operator time was between 40 and 50 minutes. None of the patients required blood transfusions. Average hospitalization was seven days. All patients were monitored through the Ambulatory Pediatric and Urological Service. Anderson-Hynes operation is the main procedure to solve the obstructive syndromes of the PUJ. It can be performed without stentings of the ureter as originally described by the author, but also by protecting anastomosis with a urinary diversion, such as JJ catheter, ureteronephrostomy or ureteropyelostomy. Even though clinical and imaging studies are sufficient for diagnose of PUJ syndromes, morphology and histology bring essential data regarding the age of the lesions.

Corresponding author: Mihail-Claudius Berechet, MD, PhD; e-mail: berechet.mihail@yahoo.com

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20. Colon cancer: clinical, macroscopic and microscopic aspects

Ruxandra-Mihaela Florescu-Tenea, Adina Maria Kamal, Paul Mitrut, Radu Mitrut, Daniel Sorin Ilie, Andrei Cristian Nicolaescu, Silviu-Adrian Marinescu

Although in developed countries the incidence of colorectal cancer is decreasing through the introduction of well-designed screening systems, the worrying worldwide increase of the mortality rate by colorectal neoplasm indicates the need for a thorough characterization of this pathology. Clinical, endoscopic, histopathological and immunohistochemical data provide important information for creating categories of patients that can benefit from intensive screening methods and for establishing the prognosis based on these data. Approximately 80% of the colorectal cancer develops from adenomas, which shows that early detection of premalignant lesions is an important step in reducing global incidence and mortality. Our study aims at providing information about the clinical, imaging and histopathological characterization of colorectal neoplasm and premalignant lesions. A total of 98 patients were evaluated, including 72 patients diagnosed with colorectal cancer and 26 with premalignant lesions. Patients underwent colonoscopy with biopsy specimens that were examined histopathologically. From the epidemiological data, we observe a higher incidence in men with a men/women ratio of 2/1, with a median age in colorectal cancer patients of 63.93 years. Different data on signs and symptoms were observed according to the colonoscopy location, with a slight difference between symptoms of patients with premalignant lesions compared to those diagnosed with colorectal neoplasm. Endoscopy showed that the rectum was the most frequent location, followed by the left colon, the tumor having a vegetative aspect in most cases. Histopathology confirms that the most common subtype is adenocarcinoma, described in 67 of the studied cases. The moderate differentiation degree is present in more than half of the cases.

Corresponding author: Adina Maria Kamal, MD, PhD; e-mail: adinaka@gmail.com

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21. Clear cell renal cell carcinomas - epithelial and mesenchymal immunophenotype

Alex Emilian Stepan, Claudiu Margaritescu, Lucian Eugen Stoica, Mioara-Desdemona Stepan, Cristiana Eugenia Simionescu

Clear cell renal cell carcinomas (CCRCCs) are the most common kidney tumors that despite current advances in diagnosis continue to have high rates of metastasis and mortality. In this study, we analyzed the cytokeratin (CK) AE1/AE3 and vimentin immunoexpression in 26 CCRCCs in relation to histopathological prognostic parameters. Immunoreactions were positive and heterogeneous in all analyzed cases. CK AE1/AE3 immunoexpression was associated with low grade and early stage lesions, while vimentin immunoexpression was associated with high grade and advanced lesions. The aspect may be used to determine the tumor heterogeneity and a better patients stratification for therapy.

Corresponding author: Claudiu Margaritescu, Professor, MD, PhD; e-mail: c_margaritescu2000@yahoo.com

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22. The effect of plasma rich in growth factors in bone augmentation after sinus lift complications: a case report

Cristian Adrian Ratiu, Mihaela Mirela Zdrinca, Adina Bianca Bosca, Flavia Ruxanda, Viorel Miclaus, Aranka Ilea

The case report describes a sinus membrane elevation procedure, where the augmentation was performed exclusively with plasma rich in growth factors (PRGF) and fibrin clot, followed by osseous regeneration at eight months. The patient exhibited a marked osseous atrophy in the premolar-molar area of the left superior alveolar process. Initially, we performed a sinus membrane elevation, with autologous bone on the sinus floor and bovine bone, followed by horizontal augmentation with autologous bone harvested from the mandibular ramus. The fragments were covered with PRGF and fibrin clot. Implants were inserted six months post-intervention, but due to the insertion high speed, a vestibular abscess occurred three months later. The implants and sinus graft were removed; after curettage, the sinus was filled with PRGF and fibrin clot. Eight months later, we observed the bone regeneration and the implants were reinserted. Along with implant insertion, bone was harvested for histological examination. Microscopically, the bone formation was revealed in the sinus, with differences between crestal and apical zones. The bone remodeling process was more advanced in the crestal zone compared with the apical zone. Bone regeneration was complete, and the bone density allowed the implant insertion with appropriate primary stability. Four months after implant insertion, the panoramic radiography and cone-beam computed tomography (CBCT) confirmed the implant osseointegration. Results obtained after using PRGF and fibrin clot alone as osseous addition materials in sinus lifting are highly promising, but in order to draw scientifically reasoned conclusions, further clinical studies are required.

Corresponding author: Adina Bianca Bosca, Lecturer, DMD, PhD; e-mail: biancabosca@yahoo.com

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23. A case of tuberculous meningitis and the role of perivascular spaces in lymph cell migration in the brain

Gabriela-Camelia Rosu, Dan Nechita, Cristina Jana Busuioc, Anca-Maria Istrate-Ofiteru, Otilia Clara Margaritescu, Iulia Diana Stanca, Daniel Pirici, Dan Bondari

Meningitis and encephalitis are inflammatory diseases in which acute and chronic inflammatory cells infiltrate leptomeninges, especially the arachnoid, and migrate through the subarachnoid space and by diapedesis, in order to extend around blood vessels and into the brain parenchyma. To what extent migrated/resident inflammatory cells participate to these interactions, or what are exactly the initial steps by which these cells reach the brain interstitium, it is not yet completely known. Recent years have brought new insights into the description of water flow circuits in the brain, suggesting that the cerebrospinal fluid enters the brain within the perivascular spaces of arteries, while interstitial fluid drains along perivascular venous sector. Moreover, it has been showed that vascular basement membranes have a complex multi-layered architecture that originates with epithelial, endothelial, smooth muscle cells and glial cells, and that the virtual space between these layers might be in fact an essential component of these perivascular spaces. Starting from a patient that presented with active pulmonary tuberculosis and with consecutive purulent-hemorrhagic meningitis and encephalitis, we have characterized here the compartments in which immune cells can be found in the brain tissue. Besides the classical histopathological description, what was of interest here, was that we identified for the first time mononucleated inflammatory cells that seemed to be present in pockets of the vascular basement membranes, small spaces devoid of red blood cells. Although this is mere a morphological observation, future high-resolution studies should clarify it this is a possible route for the immune cells entering the brain.

Corresponding author: Gabriela-Camelia Rosu, Junior Assistant, MD, PhD Student; e-mail: nicola_camelia92@yahoo.com; Dan Nechita, Teaching Assistant, PhD; e-mail: nechita_d@yahoo.com

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24. Esthesioneuroblastoma: the complete picture - case report and review of the literature

Corneliu Toader, Marian Stroi, Andrei Kozma, Dorel Eugen Arsene

Esthesioneuroblastoma (ENB), also called olfactory neuroblastoma, is a cancerous tumor originating from the olfactory neuroepithelial cells frequently invading the brain through the cribriform plate. The optimal therapy is the multimodality treatment involving a group of physicians trained in different medical specialties. Establishing a careful histopathological diagnostic and treatment planning based on a multidisciplinary approach is of paramount importance. The treatment of ENB correlates with the extent of the lesion, with surgery being the mainstay of therapy followed by postoperative irradiation. Surgery, when complete, image-verified and associated with radiation therapy results in long-term survival and presents a very low probability of illness recurrence. We present the case of a 46-year-old female with ENB, who was operated on in the Clinic of Neurosurgery of the National Institute of Neurology and Neurovascular Diseases in Bucharest, Romania, through a bifrontal craniotomy approach. Gross total resection of the intracranial extent was performed. The pathological diagnosis revealed an aggressive olfactory neuroblastoma. Three weeks after discharge from hospital, the tumor was completely resected through a lateral rhinotomy performed by an otorhinolaryngologist. Six weeks later, the patient received adjuvant therapy (radiotherapy and chemotherapy). The outcome was favorable, with no tumor recurrence at 20 months postoperatively. Our case demonstrates that even when dealing with a visibly aggressive tumor, a correct diagnosis, accurate classification and grading along with appropriate therapy ensure a favorable outcome.

Corresponding author: Andrei Kozma, MMD, PhD; e-mail: dr.ka.mailbox@gmail.com

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25. Liver hydatid cyst - cause of violent death. Case presentation

Marian Valentin Zorila, Razvan Stefan Tolescu, George Lucian Zorila, Magdalena Diaconu, Bogdan Silviu Ungureanu, Roxana Eugenia Zavoi, Oana Mariana Cristea, Feng Ifrim Chen

Liver hydatid cyst represents one of the most frequent localizations of Echinococcus granulosus tapeworm in humans. The disease progresses symptom-free in most patients, due to a slow growth rhythm of the cyst. When it reaches large sizes, the hydatid cyst causes discomfort or pain in the liver bed, low appetite, phenomena of hepatitis or cholangitis. The patients are most often diagnosed with liver hydatid cyst after imagistic investigations (radiological or ultrasound) for symptoms that, most commonly, are not related to a hydatid cyst. We present the case of an 11-year-old girl, with no pathological history, who presented forme fruste symptoms, not acknowledged by her parents, and deceased after an anaphylactic shock caused by the rupture of a liver hydatid cyst.

Corresponding author: Roxana Eugenia Zavoi, Professor, MD, PhD; e-mail: roxanazavoi@yahoo.com; Oana Mariana Cristea, Assistant Professor, MD, PhD; e-mail: oanamarianacristea@gmail.com

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26. Long disease-free survival following total sternal resection and reconstruction of the sternum with acrylic cement for unique massive sternal metastasis after operated breast cancer

Alin Dragos Demetrian, Mihai Olteanu, Ion Mindrila, Adrian Macovei, Dumitru Sandu Ramboiu, Monalisa Elena Enache, Violeta Serenada Bala, Camelia Demetrian, Mihai Popescu, Costin Teodor Streba

Unique sternal metastasis is an uncommon finding in the follow-up of operated breast cancer. We present a case of massive sternal metastasis occurred few years after radical resection of a right mammary cancer, that we solved by total sternal resection and reconstruction of sternum with acrylic cement and Vicryl mesh. The patient is disease-free five years after the operation.

Corresponding author: Adrian Macovei, Teaching Assistant, MD, PhD; e-mail: adrian.macovei@gmail.com

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27. Difficulties of clinical and histopathological diagnosis in advanced vulvar clear cell carcinoma

Catalin Gabriel Herghelegiu, Adrian Neacsu, Nuti Daniela Oprescu, Ana Elena Carbunaru, Anca Daniela Braila, Fabiana Georgiana Curea, Madalina Lucia Marcu, Raluca Gabriela Ioan, Roxana Elena Bohiltea

Clear cell carcinoma (CCC) of the female genital tract usually arises in the ovary, endometrium, cervix and vagina. A rare site for CCC is the vulva, and moreover even rarer are the cases involving the Bartholin gland. A 54-year-old female was admitted for a 1.5x2 cm tumor at the level of the right Bartholin gland. The magnetic resonance imaging (MRI) exam revealed enlarged inguinal, pelvic and para-aortic lymph nodes but no other primary tumor. Microscopic examination revealed CCC. The tumor was positive for cytokeratin 7 (CK7), paired-box 8 (Pax8), napsin A and vimentin, negative for estrogen receptor (ER), progesterone receptor (PR), calretinin, cluster of differentiation 10 (CD10), carcinoembryonic antigen (CEA), p16 and p63. Also, p53 was expressed in 30-40% and Ki67 in 70% of the malignant cells. Given the clinical, imagistic, histological and immunohistochemical features of the tumor, we concluded that the tumor is a CCC of the Bartholin gland. Aim of the study is to signal a rare case of CCC of Bartholin gland. Since there are only two other cases reported in literature, the natural history and prognosis of the disease is not known, also there are no therapeutic guidelines regarding this rare tumor so appropriate treatment is uncertain. Therefore, it is important that new cases are reported for a better understanding of this rare condition. Bartholin gland carcinoma is a pathology quite rarely encountered in practice. The positive diagnosis is eminently histological and immunohistochemistry. Bartholin gland CCC is an extremely rare diagnosis with, to our knowledge, only two other cases reported in literature, but with a potential aggressive clinical behavior and poor outcome.

Corresponding author: Nuti Daniela Oprescu, Lecturer, MD, PhD; e-mail: cnr_cata@yahoo.com

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28. Astroblastoma - reviewing literature and one case report

Daniel Mihai Teleanu, Andreea Iliesiu, Adrian Florian Balasa, Raluca Ioana Teleanu, Nicolae-Stefan Bogaciu

Background: Astroblastoma is a poorly defined central nervous system (CNS) tumor, included along with polar spongioblastoma and gliomatosis cerebri in the group of neuroepithelial tumors of uncertain origin in the June 2016 World Health Organization (WHO) Classification of tumors of the CNS. They are rare neoplasms that affect primarily patients of young ages. The purpose of this research is to highlight the uniqueness and rareness of this pathology and to emphasize on the particularities of one case managed in our Clinic. Case description: We present the case of a 54-year-old patient with a history of seizures since the age of six years old, who presented on admission with progressive worsening and unresponsiveness to treatment, starting six months prior to presentation. Brain imaging shows a right frontal mass compressing neighboring structures. Gross total resection of the tumor was performed, and histopathological examination of the surgical sample together with immunohistochemistry highlighted the presence of a low-grade astroblastoma. Conclusions: We summarized data from the literature in order to highlight aspects of this affliction: clinical presentation, imagery, surgical treatment and pathology, hoping that this will aid physicians in finding useful information on this subject, which can guide them to a good outcome. We also discussed differential diagnosis, as this type of tumor shares common features with ependymoma, meningioma, astrocytoma, etc.

Corresponding author: Daniel Mihai Teleanu, Lecturer, MD, PhD; e-mail: daniel.teleanu@umfcd.ro

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29. Alveolar rhabdomyosarcoma in an adolescent male patient - case report and current perspectives

Daniel Laurentiu Pop, Gheorghe Noditi, Ahmed Abu-Awwad, Daniel Claudiu Malita, Carmen Lacramioara Zamfir, Mirela Loredana Grigoras, Dinu Vermesan, Radu Prejbeanu, Horia George Haragus, Anca Laura Boscu, Bogdan Catalin Ciupe, Bogdan Nicolae Deleanu, Cosmin Ioan Faur, Roxana Folescu

Alveolar rhabdomyosarcoma (RMS) is a common pediatric malignant mesenchymal tumor, representing half of soft tissue sarcomas and approximately 5% of all cancers. We present the case of an adolescent male patient treated in our Department for a tumoral mass located in the middle third of the forearm. Magnetic resonance imaging (MRI) and angiography-computed tomography (angio-CT) showed a large mass located in the muscles of the anterior compartment of the forearm. Surgical treatment consisted of tumor ablation including segmental resection of the radial and ulnar arteries and of the median nerve, followed by saphenous autograft vascular bypass. The treatment plan was based on tumor type, histological grading (high), age, tumor size greater than 5 cm, unfavorable location, postoperative tumor, node, metastasis (TNM) stage II, presence of microscopic tumoral tissue in the margins of the resected piece, lymph node metastases (N1) and bone metastases (M1) found on positron-emission tomography (PET)-CT according to the German soft tissue sarcoma study (CWS)-IV 2002 protocol. The chemotherapy used Carboplatin and Topotecan. Survival was less than two years after the initial presentation. Adolescent extremity masses should raise suspicion to exclude serious malignancy. Despite early diagnosis and use of multimodal therapies, alveolar RMS prognostic remains unpredictable.

Corresponding author: Daniel Laurentiu Pop, MD, PhD; e-mail: daniellaurentiupop@yahoo.com; Cosmin Ioan Faur, Assistant Professor, MD, PhD; e-mail: faur17@gmail.com

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30. The Herlyn-Werner-Wunderlich triad (OHVIRA syndrome) with good pregnancy outcome - two cases and literature review

Dana Maria Albulescu, Andreea Elena Ceausescu, Lorena Mihaela Sas, Maria Cristina Comanescu, Cristian Constantin, Stefania Tudorache

The Herlyn-Werner-Wunderlich syndrome (HWWS) is a complex congenital malformation, originally described as a triad of symptoms: didelphys uterus, low genital obstruction and unilateral renal anomaly. The term OHVIRA is an acronym (obstructed hemivagina/hemicervix with ipsilateral renal anomaly) and refers to the same syndrome. It gained acceptance in recent years, due to reports of cases having a non-didelphys uterus (normal, septated or having other abnormalities). In the following, we report two cases with good pregnancy outcome and we provide a short discussion on published literature. We highlight differences and complications in these two cases, confirming the extreme variability of anatomic structures involved in the syndrome. Though rare, the condition allows successful pregnancies. We describe the sixth case of didelphys uterus with unique (anatomically normal) vagina and unilateral isolated hemicervix hypoplasia/atresia. Imaging has a paramount importance in the diagnosis of HWWS/OHVIRA, with magnetic resonance (MR) usually superseding the ultrasound (US) method, and providing other viscera details. US, MR and laparoscopy/laparotomy complement each other, and for describing the anatomy of the obstruction a thorough clinical examination is required. The clinical course of the pathology is not standard and the management must be tailored, but term/near-term pregnancies resulting in healthy newborns are possible in HWWS. We advocate an appropriate maternal and fetal prenatal care and long-term follow-up.

Corresponding author: Stefania Tudorache, Associate Professor, MD, PhD; e-mail: stefania.tudorache@gmail.com; Cristian Constantin, Lecturer, MD, PhD; e-mail: cristian.constantin2364@gmail.com

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31. Rare benign tumor of the larynx - laryngeal amyloidosis

Ioana Delia Horhat, Nicolae Constantin Balica, Horatiu Constantin Urechescu, Flavia Baderca, Marioara Poenaru, Caius Ion Doros, Ion Cristian Mot, Eugen Radu Boia, Carmen Aurelia Mogoanta, Alexandru Chioreanu, Alexandru Nicolae Vlaescu, Cristian Andrei Sarau

We report a case of rare benign tumor of the larynx - amyloidosis of larynx - in a 52-year-old female who presented to the Department of Ear, Nose and Throat (ENT), Timisoara Municipal Hospital, Romania, with dysphonia. The patient s first presentation was in June 2012, with a polypoid formation localized on left vocal cord. The patient underwent a suspended microlaryngoscopy (SM) with tumor removal followed by histopathological examination, which revealed a laryngeal amyloidosis. The tumor recurred in 2013, 2014, 2016, 2017 and 2018. The patient underwent tracheotomy, followed by SM with endoscopic CO2 laser procedures, in order to remove the tumor and to ensure the airway. The follow-up was for six years. In May 2018, amyloid was located in subglottis, glottis and left false vocal fold. The patient needed five revision surgical procedures. The patient did not developed systemic amyloidosis during the follow-up period.

Corresponding author: Flavia Baderca, Associate Professor, MD, PhD; e-mail: flaviabaderca@yahoo.com; Horatiu Constantin Urechescu, MD, PhD; e-mails: urechescu.horatiu@umft.ro, uhc_83@yahoo.com

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32. Double unilateral functioning adrenocortical adenomas

Konstantinos Sapalidis, Dimitrios Giannakidis, Stella Laskou, Georgia Karayannopoulou, Triantafyllia Koletsa, Vasileios Rafailidis, Katerina Zarampouka, Sotiris Sotiriou, Konstantina Spyridaki, Isidora Stamenitou, Isaak Kesisoglou, Ion Paun

Double functioning adrenocortical adenomas, occurring in the same gland is an extremely rare condition. This paper presents two cases of double functioning adrenocortical adenomas within the same adrenal gland, causing primary aldosteronism. Diagnosis was set histopathologically in one case since magnetic resonance imaging (MRI) failed to distinguish the two entities. In each case, a laparoscopic adrenalectomy was conducted. When preoperative imaging studies fail to report the presence of double adrenocortical adenomas, histopathology reports should be comprehensive enough so as to reveal such rare lesions.

Corresponding author: Konstantinos Sapalidis, Assistant Professor, MD, PhD; e-mails: sapalidis@med.auth.gr, sapalidiskonstantinos@gmail.com

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33. Antimesenteric gastrointestinal tract duplication undergoing non-ulcerative perforation

Dimitrios Sfoungaris, Mitroudi Magdalini, Ioannis Patoulias, Christina Panteli, Ioannis Valioulis

Duplications of the gastrointestinal tract are rare malformations, most commonly presenting as cystic structures growing within the smooth muscle wall. Very rarely, they are completely detached from the tract. Several theories have been proposed regarding their embryological development, but no single one has been able to account for all of the described variants. The most common type of duplication is related to the small bowel and develops at its mesenteric border, assuming a spherical or tubular shape. Their clinical manifestations vary, depending mainly on their localization and size. Most commonly, they cause subacute abdominal pain and intestinal obstruction in children of less than two years of age. We present a case of an 8.5-year-old girl, investigated for right lower quadrant abdominal pain. On ultrasound scan, a cystic mass indicative of a duplication cyst was discovered and she underwent a laparotomy. A tense cystic spherical mass 2.2 cm in diameter was excised from the terminal ileum, 4 cm from the ileocecal valve. The cyst had the characteristics of a gastrointestinal tract duplication, except from the fact that it was located on the antimesenteric border of the intestine. On the other hand, the lesion did not present the characteristic features of a Meckel s diverticulum. According to our knowledge, this is the first report of an intestinal duplication cyst appearing on the antimesenteric intestinal border.

Corresponding author: Dimitrios Sfoungaris, Assistant Professor, MD; e-mails: dsfounga@auth.gr, surgicalpediatrics@gmail.com

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34. Multiple congenital anomalies of carotid and vertebral arteries in a patient with an ischemic stroke in the vertebrobasilar territory. Case report and review of the literature

Dragos Catalin Jianu, Silviana Nina Jianu, Gratian Dragoslav Miclaus, Georgiana Munteanu, Traian Flavius Dan, Claudia Barsan, Mihnea Munteanu, Horia Tudor Stanca, Andrei Gheorghe Marius Motoc, Octavian Marius Cretu

The congenital anomalies of the supra-aortic arteries and their branches as potential risk factors for cerebrovascular insufficiency are not yet fully investigated and clarified. This report describes the case of a 68-year-old man who was admitted in our Clinic for an acute ischemic stroke in the vertebrobasilar territory. Extracranial color-coded duplex sonography (CCDS) and computed tomography angiography revealed a combination of congenital anomalies of the neck arteries: left internal carotid artery hypoplasia, left common carotid artery hypoplasia, right vertebral artery hypoplasia and the emergence of the left vertebral artery directly from the aortic arch. The aim of this article is to emphasize the value of CCDS as an accurate, non-invasive method of assessing the neck arteries and, also, the importance of the morphological anomalies of the carotid and vertebral arteries in the cerebral hemodynamics.

Corresponding author: Andrei Gheorghe Marius Motoc, MD, PhD; e-mail: amotoc@umft.ro; Claudia Barsan, MD; e-mail: barsan.clau@yahoo.com

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35. A rare case of a Wilms tumor: case report

Cristina Elena Singer, Laura Daniela Marinau, Carmen-Simona Cosoveanu, Liliana Streba, Ileana-Octavia Petrescu, Mioara-Desdemona Stepan, George Alin Stoica, Diana-Maria Trasca

The nephroblastoma or Wilms tumor (WT) is the most common renal tumor in childhood, representing approximately 6-7% of all pediatric cancers, with a yearly incidence of 10 cases in one million children less than 15 years old, and continues to arouse interest by remarkable actual therapeutic successes, consecutive to the multidisciplinary approach. Its maximum incidence is around the age of 3-3.5 years old, having an equal frequency in males and females. We present the case of a child, aged three years and five months, who was diagnosed with WT (nephroblastoma) with triphasic pattern, stage II tumor, and admitted to the Department of Oncopediatry for chemotherapeutic treatment and clinico-biological investigations.

Corresponding author: Liliana Streba, Teaching Assistant, MD, PhD; e-mail: lilianastreba@gmail.com

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36. Clinical and morphological aspects of lateral femoral condyle status after an osteochondral fracture. A case report

Pompiliu Horatiu Petrescu, Dana Cristina Bratu, Marius Octavian Pricop, Delia Mira Berceanu-Vaduva, Marcel-Mihai Berceanu-Vaduva, Jenel Marian Patrascu, Venera Margareta Bucur, Gabriel Ovidiu Dinu, Dorela Codruta Lazureanu

Although osteochondral fractures of the lateral femoral condyle are uncommon, fixation of the fragments is recommended, mostly when is about young athletes with such post-traumatic pathology. We present a case of a professional handball player teenager female, with a lateral femur condylar osteochondral fracture after a fall with the right knee in extension and in internal rotation. Magnetic resonance imaging (MRI) showed an osteochondral fracture of the lateral femoral condyle, 34.6 mm on long axis, impossible to manage arthroscopically, because of the size and the location of the detached fragment. The solution was the lateral knee arthrotomy allowing the evacuation of the hemarthrosis and preparation of the fracture site, then reduction and fixation of the fracture with absorbable cannulated pins. This procedure is of choice only when is enough bone in the detached fragment to permit the internal fixation and bone-to-bone healing with cartilaginous tissue stabilization through the fibro-cartilaginous rim that would seal the cartilage surface. Postoperative MRI proves that the fragment is settled in its hooked position with repairing of the articular congruity, so the recovery exercises program allow the regaining of the knee mobility with a restart of her sportive activity later.

Corresponding author: Dana Cristina Bratu, MD, PhD; e-mail: danacristinabratu@yahoo.com

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37. Neurosurgery in Romania in the centenary of the Great Union (1918-2018)

Aurel George Mohan, Mircea Vicentiu Saceleanu, Andrei Alexandru Marinescu, Mihai Popescu, Alexandru Vlad Ciurea

Neurosurgery is one of the newest medical specialties in the world, having less than 100 years since its definition as a stand-alone surgical specialty by Harvey Cushing (1869-1939). Its emergence required several special prerequisites, which were met only in the mid-19th century: knowledge of neuroanatomy, function of nervous centers and main cortical area topography, standard asepsis-antisepsis rules, neuroimaging, safe and longer general anesthesia, hemostasis and coagulation techniques and of course knowledgeable, skillful and bold surgeons. The emergence of neurosurgery in Romania has a profound bivalent origin: French and American. The first Romanian neurosurgical center was founded by Alexandru Moruzzi, in 1933, in Iasi. He was a direct student of the first French neurosurgeon Thierry de Martel, in Paris. The other neurosurgical center in Romania was founded by Dumitru Bagdasar, in 1935, in Bucharest. He studied directly under the first neurosurgeon in the world: Harvey Cushing (Boston, USA). Considering their success and international recognition against tremendous odds, the founding fathers of Romanian neurosurgery represent an example of intelligence, skill, courage and dedication for all future neurosurgeons.

Corresponding author: Mircea Vicentiu Saceleanu, MD, PhD; e-mail: vicentiu.saceleanu@gmail.com

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38. Ethical governance of the medical research: clinical investigation and informed consent under the new EU Medical Devices Regulation (2017/745)

Daniel-Alin Olimid, Anca Parmena Olimid, Feng Ifrim Chen

Purpose: The paper focuses on the ethical appraisal of the clinical investigations (CIs) and the informed consent within the new European Union (EU) legislation on medical devices (MDs). The Regulation (EU) 2017/745 of the European Parliament and of the Council was adopted on 5 April 2017 and entered into force on 25 May 2017, repealing the Council Directives concerning Medical Devices 93/42/EEC and the Active Implantable Medical Devices 90/385/EEC. Background: For the past thirty years, the EU legislation on MDs has been updated by several directives: Council Directive 90/385/EEC on Active Medical Devices (1990); Council Directive 93/42/EEC on Medical Devices (1993) and Council Directive 98/79/EC on In vitro Medical Devices (1998) aiming to frame the MDs market development. Content: From the ethical perspective, the present article investigates the new rules concerning the CIs of the MDs for human use and accessories for such devices conducted in the EU by highlighting new regulatory aspects: (1) the framework of the clinical evaluation and CI; (2) the relevant definitions; (3) the ethical principles related to CIs; (4) the informed consent; (5) the role of the national ethics committees. Conclusions: Although the new guidelines enable an extension of the definition of medical device and the harmonization of the rules for the placing on market and putting into service of the medical devices, it also regulates the MDs industry to ensure clinical benefits for patients and high standards of quality and safety.

Corresponding author: Daniel-Alin Olimid, Lecturer, PhD; e-mail: olimiddaniel@yahoo.com

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