ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 51 No. 3, July-September 2010

1. Prostate lesions with cribriform / pseudocribriform pattern

Alis Dema, Angela Borda, Elena Lazar, Codruta Lazureanu, Sorina Taban, Denisa Anderco, Marioara Cornianu, Anca Muresan, Diana Herman, Andrada Loghin, R. Cornea, Alexandra Faur

Prostate lesions with cribriform / pseudocribriform architecture range from normal histological structures to infiltrative carcinoma. In each group of lesions with cribriform architecture (benign, premalignant and malignant intraductal or infiltrating), there are situations in which histological classification of the lesion is difficult or impossible on routine stains. A more wide-scale application of the immunohistochemical investigation for clearing up the problematic prostate lesions led to the definition and reclassification of cribriform lesions in distinct categories and sometimes very different in terms of progression, prognosis and treatment. This paper proposes an overview of the prostate lesions with cribriform / pseudocribriform architecture, emphasizing the morpho-immunohistochemical criteria for positive and differential diagnosis.

Corresponding author: Alis Dema, Professor, MD, PhD, e-mail: dema_alis@yahoo.com

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2. Cellular interactions in prostate cancer genesis and dissemination. Looking beyond the obvious

C. Tomuleasa, G. Kacso, Olga Soritau, S. Susman, A. Irimie, Piroska Virag

Similar to normal organs arising from normal stem cells, cancers can be viewed as organs composed of heterogeneous cellular populations arising from cancer cells with indefinite proliferation abilities. The continuous malignant progression is maintained by the proliferation of cancer stem cells and not the progeny that undergo limited proliferation before terminally differentiating. Effective therapy must eradicate malignant cells with unlimited clonogenic expansion within the primary tumor bulk. Thus, resolving both the specific cell of origin for prostate cancer and the interactions between the cells and the surrounding microenvironment within the cancer stem cell niche are crucial to appropriately define rational targets for therapeutic intervention and cure prostate cancer.

Corresponding author: Ciprian Tomuleasa, e-mail: ciprian.tomuleasa@gmail.com

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3. Recent data about the role of human papillomavirus (HPV) in oncogenesis of head and neck cancer

Fl. Badulescu, Anda Crisan, Adriana Badulescu, M. Schenker

Human papillomavirus (HPV) is a small circular DNA-virus and the high-risk types 16, 18 is implicated in oncogenesis of head and neck cancer - especially oropharynx (tonsil and base of tongue), poorly differentiated (the basaloid type), locoregional advanced stage, poorly differentiated, at the younger male, non-smokers, non-drinkers, sexual behaviors. The prognostic is favorable of human papillomavirus tumor status for patients with oropharynx squamous cell carcinoma treated with radiotherapy (accelerated fractionation without total dose reduction). The impact of HPV-vaccination (ACIP 2007) decreasing the incidence of oropharyngeal cancer, but that patients HPV-positive, have good prognostic in generally (two-year overall survival: 95%, two-year progression-free survival: 88%), therefore HPV-vaccination in routine practice it is controversy.

Corresponding author: Florinel Badulescu, Professor, MD, PhD, e-mail: cpopescu67ro@yahoo.com

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4. Human blastocyst culture in IVF: current laboratory applications in reproductive medicine practice

E. S. Sills, G. D. Palermo

For fertility patients undergoing in vitro fertilization (IVF), blastocyst culture brings a number of potential advantages over laboratory techniques leading to traditional cleavage-stage embryo transfer. Because day 2-3 embryos normally should transit the oviduct only, their direct exposure to an intrauterine microenvironment is physiologically inappropriate. This mismatch is obviated by blastocyst transfer. Moreover, the nutritional milieu inside the fallopian tube is not the same as within the endometrial compartment, a feature possibly antagonistic to implantation when a day 2-3 embryo is placed directly within the uterus. Delaying transfer to day 5-6 may also improve reproductive outcome by reducing risk of embryo expulsion, given increased myometrial pulsatility measured at day 2-3. However, rigid reliance on a blastocyst culture approach will more often result in treatment cancellation due to embryo loss (no transfer), or having fewer embryos for cryopreservation. The development of sequential media to support embryos in extended in vitro culture was a significant laboratory refinement, since it enabled direct observation of embryos to improve transfer selection bias. This approach, in tandem with blastocyst cryopreservation, leads to fewer embryos being transferred and reducing multiple gestation rate. This review discusses key features of human blastocyst culture and its application in clinical reproductive medicine practice.

Corresponding author: Eric Scott Sills, MD, e-mail: drscottsills@sims.ie

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5. Intraductal papillary mucinous tumors of the pancreas

Daniela Dumitrescu, Carmen Florina Popescu, A. Saftoiu

Intraductal papillary mucinous tumors (IPMTs) are benign and malignant lesions that arise from the epithelial lining of main pancreatic duct and/or branch pancreatic ducts, with excessive mucin production (especially hyperplastic/adenomatous variety). Based on the degree of cytoarchitectural atypia on microscopic examination, IPMTs are classified as benign, borderline, carcinoma in situ and invasive tumors. Imaging examinations are very important to establish the diagnosis. Two or more tests are usually required. Transabdominal ultrasound, endoscopic ultrasound, computed tomography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangio-pancreatography have been used for the diagnosis of IPMTs. The correct diagnosis, achieved until recently only with endoscopic retrograde cholangiopancreatography, can be currently obtained with non-invasive imaging modalities, particularly computed tomography and magnetic resonance imaging. Confirmation of the diagnosis requires, however, endoscopic-ultrasound fine-needle aspiration biopsy, followed by cytological or microhistological exams. The natural evolution of IPMTs is still not clear and the management is consequently still evolving.

Corresponding author: Daniela Dumitrescu, Assistant Professor, MD, PhD, e-mail: daniela.dumitrescu@gmail.com

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6. Electron microscopy analysis of skin biopsies in CADASIL disease

Carmen Elena Cotrutz, Anca Indrei, L. Badescu, Cristina Dacalu, Monica Neamtu, Gabriela Florenta Dumitrescu, Felicia Stefanache, T. Petreus

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is an inherited vascular disorder, non-amyloid and non-atherosclerotic, affecting predominantly the central nervous system. We examined samples of skin biopsies from six patients (men, 43-52-year-old), admitted for treatment in the Neurology Clinic regarding the presence of partial motor impairment on upper and lower right limbs, facial asymmetry and phrasing impairment (three of the patients); These three patients had family history remarkable for early-onset strokes: mother and two brothers deceased by early strokes (40-50-year-old). Skin biopsy samples were fixed in glutaraldehyde and post-fixed in osmium tetroxyde. After dehydration, tissue samples were embedded in Epon. Ultrathin sections were mounted on copper grids and stained with uranyl acetate and lead citrate as usual and examined with a transmission electron microscope Phillips CM100. In all cases ultrastructural study showed granular osmiophilic material (GOM) in extracellular locations, between degenerating smooth muscle cells in dermal arteries or in their indentations. Deposits of GOM varied in size and electron density. Degeneration and loss of smooth muscle cells (SMCs) leads to abnormal enlargement of the space between these cells Ultrastructural analysis in three cases showed chromatin condensation and peripheral aggregation of nuclear material suggesting cells entry to apoptosis. These aspects and the marked destruction of the vascular wall were correlated with MRI findings and the severity of clinical manifestations at these patients. Our study showed that findings of GOM deposits, degeneration and loss of SMCs (probably by apoptosis), cell adhesion elements disturbance are characteristic for CADASIL disease and sufficient for diagnose of certainty. Moreover, electron microscopy analysis of skin biopsies is a useful tool for a differential diagnosis and can be considered as first choice method.

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

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7. Immunohistochemical study of p53 and Ki67 in a group of patients with mammary carcinoma

D. M. Plesan, Claudia Valentina Georgescu, Nicoleta Patrana, C. Plesan, D. Stoica

The study was done over a period of 10 years, 1996-2005 and it included 562 mammary cancer patients. Of the 562 cases, 100 cases of invasive mammary carcinoma included in this study were investigated from an immunohistochemical point of view. The p53 overexpression was more frequently seen in patients under 50 (23 cases, that is 54.76%), compared to those over 50 years old (19 cases, that is 45.24%). The positive p53 tumors were more often over 2 cm big. The invasive ductal carcinomas were p53-positive in 40 cases (44.44%) of all invasive ductal carcinoma cases, and the invasive lobular carcinomas were only positive in two cases (20%) of all mammary invasive lobular carcinoma cases. Most cases that had the overexpression of the p53-protein (30 cases that is 71.43%) had a high histological degree (G3), and only 12 cases (28.57%) had a low histological degree (G1 and G2). The overexpression of the p53-protein was present in all cases that had a heterogeneous phenotype (with one of the hormonal receptors being negative), in over half of the cases that had both hormonal receptors negative (59.37% of ER-/PR- phenotype cases) and in only 21.05% of cases that had ER+/PR+ phenotype. The association of the p53 overexpression (p53 over 10%), with the HER2 (2+ or 3+ score) overexpression was seen in seven patients of the 100 invasive mammary carcinoma cases included in this study. Consequently, 16.66% of p53 positive cases had associated positivity for HER2. Most cases that were p53 positive had an increased proliferation activity, as determined with Ki67. The Ki67 immunostaining analysis has made it clear that this marker has positivity presence in all cases. The vast majority of cases had a nuclear marking to Ki67, but two cases (2% of cases) had a cytoplasmatic / membrane staining.

Corresponding author: Dragos Mihai Plesan, MD, e-mail: dragosmax2000@yahoo.com

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8. The utility of histopathologic examination in appreciation of mandibular osteoporotic status

C. A. Ratiu, V. Miclaus, T. Maghiar, Ioana Adela Ratiu, Diana Osvat, C. Ober

The study was performed on 14 female patients aged between 54 and 83 years, presented for insertion of mandibular implants and diagnosed with systemic osteoporosis on DXA. Radiological examination showed no striking maxillar bone rarefactions or changes in the mandibular cortex form that allows the diagnosis of osteoporosis at the jaw. To obtain informations on the health status of mandibular bone in these patients, we considered it appropriate to do histopathological investigations on fragments of bone harvested from implant insertion area. To this end, fragments of bone harvested when performing the new alveolus were fixed in Stieve mixture, decalcified with trichloroacetic acid and included in paraffin. Five-micrometer thick sections were stained with Goldner's Trichrome method and examined microscopically. Histopathology revealed changes of different intensity in the organic and vascular components of the mandibular bone, in all patients studied, with differences from case to case. Thus, confirming that patients with systemic osteoporosis diagnosed by DXA at the femoral neck and/or the vertebrae have histological changes in the mandibular bone, but the extent of damage is different. Providing detailed information about organic component and bone vascularization, crucial components in the early stages of osseointegration, histopathology is more useful for assessing mandibular osteoporotic status, compared with methods of investigation that aim only the mineral component, mineralization being the final stage of osseointegration. Highlighting mandibular osteoporotic early lesions by histopathological examination allows a patient-specific therapeutic approach and could be an accurate method of assessment for required osseointegration period, depending on the degree of impairment.

Corresponding author: Cristian Adrian Ratiu, Senior Lecturer, MD, PhD, e-mail: ratiu_cristian@yahoo.com

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9. The study of p53 and CA19-9 prognostic molecular markers in colorectal carcinomas

Georgeta Afrem, Stefania Craitoiu, Cl. Margaritescu, S. S. Mogoanta

Immunohistochemistry represents a relatively new identification technique of cellular and tissular antigens due to an antigen-antibody binding interactions, applied more and more in the pathology laboratories for positive and differential diagnosis of premalignant and malignant lesions and also for evolutive prognosis of tumoral formations. Immunohistochemistry coloration is based on the antigen-antibody affinity, the antibody binding situs being identified either by antibody coloration direct methods or by using an indirect method where the marking is supplied by antibodies called secondary or even tertiary. The present study is based on the immunohistochemical investigation of some molecular markers with a prognosis value in colorectal cancers (CCR), like the antibody p53 immune expression and of some factors supposed to have prognosis value, such as CA19-9 (carcinoembryonic antigen, carbohydrate antigen or Lewis antigen). In the last decade, the studies have tried to define the prognosis of the molecular markers that allow the identification of the patients with recurrent risk after surgical treatment and who can benefit from chemotherapy in an efficient way. The purpose of the study on immunohistochemical markers is to aim towards the treatment based on molecular phenotypes of colorectal tumors. In 2000, according to the Consensus Conference of the Colorectal Working Group of the American Joint Committee on Cancer Prognostic Factors (AJC), there were established four categories of prognosis factors in colorectal cancers based on the practical importance and the number of studies referring to them. The present study is centered on the prognosis factors from the second B category (p53 oncoprotein expression) and the fourth category (CA19-9 immunomarker expression).

Corresponding author: Georgeta Afrem, MD, e-mail: amc.ro@rdslink.ro

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10. Vascular and nerve lesions of the diabetic foot - a morphological study

Raluca Maria Popescu, C. Cotutiu, Mariana Graur, Irina-Draga Caruntu

The microcirculation in neuropathic diabetic feet is the subject of the same changes found in other end organs of the diabetic patients. In diabetic neuropathy, abnormal neurogenic regulation of the hemodynamics in the small vessels may contribute to the development of microangiopathy, which is manifested as increased basement thickening. Material and Methods: The study has been made on a group of 25 patients: nine with diabetes mellitus type 1 and 16 patients with diabetes mellitus type 2. All patients were affected by peripheral diabetic neuropathy and showed various degrees of lesions on the foot level. All cases required amputations done at the lower extremity of the limbs. Tissue fragments were processed for the standard histopathological exam, using Hemalaun-Eosin, trichromic Szekely and van Gieson staining. Results: The histopathological examination revealed on the skin level - ulcerations covering large areas, while entire sections showed hyperacanthosis. At the dermis level, the microscopic panel was dominated by the presence of the inflammatory infiltrate. The absence or the degeneration of the sweat glands, the presence of venous stasis and perivascular bleedings completed the morphological panel of the dermis. On the microcirculation level, the endothelial cells have a flat smooth inflated aspect. In the case of the large arterioles and arteries of muscular type, we observed the presence of the fibrous tissue on the level of media, calcium deposits on intima, mediocalcinosis. Conclusions: The identification of vascular and nervous morphological structures in the complicated diabetic foot allows the extension of the knowledge related to the pathological background of this condition. The vascular lesions, which appeared on the microcirculation level, are consequently involving arterioles and arteries of muscular type and are being accompanied by nervous lesions shown through morphological changes of the peripheral nerves. The overall morphological contest of the complicated diabetic foot involves lesions of the epidermis, dermis, and muscles.

Corresponding author: Irina-Draga Caruntu, Professor, MD, PhD, e-mail: irina_caruntu@yahoo.com

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11. The three-dimensional modeling of the complex virtual human elbow joint

Daniela Tarnita, C. Boborelu, D. Popa, Corina Tarnita, Ligia Rusu

The paper presents the algorithm to obtain a 3D virtual human elbow joint using CT images. For that purpose, we used CAD parametric software, which allows defining models with a high level of difficulty including complex 3D shapes. The virtual biomechanical system of the human elbow containing bones, ligaments and muscles is studied using the finite elements method and will be prepared for kinematical and dynamical simulations. The 3D virtual model will be useful for future studies concerning prosthesis optimization, improving the performances of endo-prosthetic and exo-prosthetic devices, different implants and prosthetic systems for normal and pathological situations, structures which are acted upon by SMA artificial muscles or which contain SMA elements.

Corresponding author: Daniela Tarnita, Professor, Engineer, PhD, e-mail: dtarnita@yahoo.com

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12. Immunocytochemical expression of p16INK4a and HPV L1 capsid proteins as predictive markers of the cervical lesions progression risk

Carmen Ungureanu, Demetra Socolov, Gabriela Anton, Maria Sultana Mihailovici, S. Teleman

Genital HPV infections are extremely common but most of them are spontaneously cleared by the host immune response. The main problem is how to identify the HPV-HR positive patients who are at risk of progressive disease. Aim: The purpose of this study was to investigate the uterine cervix lesions concerning the HPV status appreciated through the immunocytochemical expression of the L1 HPV and p16INK4a proteins. Material and Methods: 76 women who tested positive for HPV were selected from a cohort of 374 patients. In this study were detected the immunochemical expression of HPV L1 capsid protein and p16INK4a in LBC samples. Results: The p16INK4a positive rate was expressed in 56.57% of all the cases. The percentage grew from 0% in NILM cases to 100% in SCCs cases (p-value <0.00001). The HPV L1 capsid protein positive was expressed in 12.50% of NILM cases, 33.33% of ASC-US, 50% of LSIL, 18.51% of HSILs cases, but 0% in the SCC group (p-value =0.01). The L1-/p16+ pattern was found in 21.87% of LSIL, 81.48% of HSIL, and 100% of SCC cases (p-value <0.00001). The association of these two markers (L1 and p16INK4a) raises the accuracy of the diagnostic from 64% for HPV L1 capsid protein and respectively 87% for p16INK4a to 91% when they are associated. Conclusions: The combination of L1 capsid protein and p16 appears to be useful for an early diagnosis and may be able to identify the patients with risk of lesion progression.

Corresponding author: Carmen Ungureanu, Assistant Professor, MD, e-mail: carmen.ungureanu@morfop.umfiasi.ro

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13. Assessment of sagittal and vertical skeletal patterns in Romanian patients with obstructive sleep apnea

Aurelia Magdalena Enache, Vanda Roxana Nimigean, Fl. Mihaltan, Andreea Cristiana Didilescu, Ioana Munteanu, V. Nimigean

Objective: To establish the sagittal and vertical skeletal pattern of the Romanian patients with obstructive sleep apnea (OSA). Patients and Methods: Lateral cephalograms of forty patients, divided in two groups, group I - twenty patients with OSA (15 males and five females) and aged between 34-76 years and group II (control group) - twenty patients with class II malocclusion (eight males and 12 females), aged between 22-40 years, were analyzed for linear and angular skeletal parameters. Results: For group I - most often, the mandible was in posterior position, the mean value for SNB angle being 76.77 degrees; maxilla tended to be retruded, too. The maxillo-mandibular antero-posterior (AP) relationship was class II in 90% of the cases. A clockwise rotation of the mandible was registered in a vertical plane (mean value SN, ML: 29.82 degrees), the facial height ratio being in a normal range of values. There was a medium positive correlation between ANB angle and apnea/hypopnea index (AHI), while SNA showed a quadratic relationship with AHI. Using t-test, in order to compare the sagittal and vertical skeletal pattern of the two groups, it can be stated that there is a statistical significant difference for antero-posterior (AP) position of the mandible, for the group II mandible retrognathia being more pronounced than in group I. Conclusions: Romanian patients with OSA had a retrognathic sagittal pattern with a class II antero-posterior relationship. A statistical significant positive correlation between AHI and ANB suggests that the class II antero-posterior maxillomandibular relationship can predispose to OSA.

Corresponding author: Magdalena Enache, Assistant Lecturer, DDS, PhD, e-mail: enache_magdalena@yahoo.com

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14. Steatosis and serum lipid patterns in patients with chronic viral hepatitis: differences related to viral etiology

C. C. Vere, Daniela Neagoe, C. T. Streba, Ileana Prejbeanu, G. Ianosi, Violeta Comanescu, D. Pirici

Lipid metabolism disorders related to viral etiology are described in chronic viral hepatitis, independent of age, gender and liver synthetic function. Steatosis is present, especially in chronic hepatitis C but also in chronic hepatitis B. Although liver biopsy is the gold standard in determining presence of steatosis, its presence can be determined by ultrasonographic examination as an initial screening test. Our aim in this study was to evaluate the presence of steatosis in chronic hepatitis B and C, to determine its frequency in both hepatitis type, and to explore possible relationships between presence of steatosis, lipid metabolism disorders and viral etiology. Our study lot included 66 patients, 36 subjects with chronic hepatitis C, and 30 with chronic hepatitis B. We only encountered significant levels of steatosis in the chronic hepatitis B sub-group. We found the average age, cholesterol, triglyceride, HDL-C, VLDL-C levels in the group with steatosis to be significantly higher than those in the group without steatosis (p<0.05). Ultrasound reports of hepatic steatosis were particularly associated with histological inflammation, as well as fibrosis; however, the sensitivity and specificity of steatosis on ultrasound was poor when compared to steatosis on biopsy. Hepatic steatosis was significantly more frequent in chronic hepatitis C than in chronic hepatitis B. Severe inflammation and advanced fibrosis were more frequently found in HCV-infected patients with steatosis than in patients without steatosis.

Corresponding author: Cristin Constantin Vere, Associate Professor, MD, PhD, e-mail: vere_cristin@yahoo.com

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15. Correlations between the gingival crevicular fluid MMP8 levels and gingival overgrowth in patients with fixed orthodontic devices

Petra Surlin, Anne Marie Rauten, L. Mogoanta, Izabella Silosi, B. Oprea, D. Pirici

Levels of metalloproteinase 8 (MMP8) in gingival crevicular fluid were studied in case of treatment with fixed orthodontic appliances. It were found a relationship between its levels and stages of the treatment under a good control of the bacterial plaque. Gingival overgrowth (GO) during the orthodontic treatment was traditionally considered as an inflammatory reaction consecutive of bacterial plaque accumulation because of difficult hygiene in those patients. Our study starts from the hypothesis that the gingival volume growth during the fixed orthodontic treatment appears at the beginning, without any inflammatory signs, as a result of the mechanical stress and periodontal remodeling during the orthodontic dental movement, the MMP8 acting as an indicator of this situation. Material and Methods: Twenty-two patients received a fixed orthodontic treatment. Periodontal examination took place one hour before and one hour, four and eight hours and weekly after until eight weeks. At each session gingival crevicular fluid (GCF) was sampled and the level of MMP8 was determined. At� the appearance of gingival overgrowth (GO) gingivectomy was performed. Results: In the 13 patients that did not develop gingival overgrowth, the levels of MMP8 increased in the first 4-8 hours after orthodontic appliance and then fall to the initial level. In the nine patients with gingival overgrowth, the MMP8 levels in GCF continued to rise until the appearance of GO. In cases of GO with inflammation the levels of MMP8 were significantly higher than in cases of GO without inflammation. The expression of MMP8 in hypertrophied gingiva was more intensive in cases of GO with inflammation. Conclusions: It is possible that the MMP8 values in GCF to be a marker of the GO onset. MMP8 determination and monitoring at shorter time intervals may lead to a better control of the bacterial plaque and avoidance of gingival inflammation.

Corresponding author: Petra Surlin, Associate Professor, MD, PhD, e-mail: vsurlin@hotmail.com

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16. Radiographic study of carrying angle and morphometry of skeletal elements of human elbow

B. Kumar, Shakunthala Pai, Biswabina Ray, Snigdha Mishra, Siddaraju K S, A. K. Pandey, Binu S

Lateral obliquity of the forearm from the arm when the forearm is supinated and extended is called carrying angle. In this study carrying angle was measured using radiographs of adult individuals and morphometry was done on dry bones taking part in formation of human elbow (on lower end of humerus-trochlear angle and inclination angle of olecranon fossa, on upper end of ulna-olecranon-coronoid angle and length and width of inferior medial trochlear notch). On radiographs, the difference between male and female carrying angle and difference between carrying angle of right and left limbs (in both sexes together as well as in same sex) was statistically not significant. All the morphometric parameters measured in this study did not show any significant sexual dimorphism or difference between right and left side except the inclination angle of olecranon fossa, which was significantly more on right side. Different findings of carrying angle as reported by various authors could be due to racial difference or due to different methods used to measure carrying angle. Morphometric parameters were similar to findings of radiographic method of measuring carrying angle. These factors should also be considered in construction of elbow prosthesis as well as use of carrying angle in identification of skeletal remains.

Corresponding author: Brijesh Kumar, Assistant Professor, MD, e-mail: drbrijeshkumar@gmail.com

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17. Cytomorphometric analysis of buccal mucosa of tobacco chewers

Alka Harish Hande, Minal S. Chaudhary

Objective: The objective of the present study was to assess the effect of tobacco chewing on buccal mucosa by using cytomorphometry. Study design: We compared the cellular diameter (CD), nuclear diameter (ND) and the ratio of nuclear diameter to cellular diameter (N/C) of buccal mucosa squames of normal subjects (N) with buccal mucosa squames of tobacco users without lesion (A), with tobacco-lime lesion (B), leukoplakia (C), and oral squamous cell carcinoma (D). The study group consisted of 125 patients divided into five groups (N, A, B, C and D) between the ages of 21 and 75 years. Results: The mean of the cellular diameter (in micrometers) of group N, A, B, C, and D was 72.86+/-5.26, 68.30+/-3.02, 62.13+/-3.29, 57.75+/-4.66, 54.51+/-4.66 respectively (p<0.01). The mean of the nuclear diameter (in micrometers) of group N, A, B, C, and D was 8.70+/-1.30, 8.98+/-1.08, 9.06+/-0.83, 9.12+/-1.06, and 11.04+/-1.46 respectively (p<0.01). The mean of the ratio of nuclear diameter to cellular diameter of group N, A, B, C, and D was 0.11+/-2.00, 0.13+/-1.82, 0.14+/-1.35, 0.16+/-3.11, 0.21+/-4.51 respectively (p<0.01). Univariate analysis of variance (ANOVA) showed a significant group effect for cellular diameter, nuclear diameter and ratio of nuclear diameter to cellular diameter. Multiple comparison tests by Tukey-HSD procedure revealed a significant decrease in the mean cellular diameter, increase in the nuclear diameter and ratio of nuclear diameter to cellular diameter. Conclusions: Cytomorphometric changes could be the earliest indicators of cellular alterations. There is progressive decrease in cellular diameter, increase in nuclear diameter and increase in ratio of nuclear diameter to cellular diameter in smears from all tobacco users, as compared to normal subjects. This indicates that there could be cause-effect relationship between tobacco and quantitative alterations.

Corresponding author: Alka Harish Hande, Assistant Professor, MDS, e-mail: alkahande1@yahoo.com

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18. Renal artery variations: embryological basis and surgical correlation

Virendra Budhiraja, Rakhi Rastogi, A. K. Asthana

Understanding anatomy of the vascular variations of kidney is essential for the clinician to perform procedures such as renal transplantation, interventional radiological procedures and renal vascular operations more safely and efficiently. In order to facilitate the clinical approaches, we studied renal arterial pattern in 50 formalin-fixed cadavers, on 100 kidneys. We observed prehilar multiple branching patterns in 11 (11.66%) cases, duplication of renal artery in eight (8.33%) cases and superior polar artery in seven (6.66%) cases. In the present study findings discussed with its clinical correlation.

Corresponding author: Virendra Budhiraja, Associate Professor, e-mail: budhirajasimran46@gmail.com

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19. Maturation of the neuromuscular junction in masseters of human fetus

W. Molina, E. Reyes, N. Joshi, Ana Barrios, L. Hernandez

Objectives: The aim of the present investigation is to examine if the histological maturation of the neuromuscular junction in the masseters of human fetuses has already begun by the 12-th week of gestation or not. Material and Methods: Twenty-four masseter muscles from 14 human fetuses at gestational age 12 weeks were divided into two groups. In the first group, muscle sections were stained with Bielschowsky and Holzer stains for examination of neurofibrils and glial cells respectively. In the second group, rhodamine and fluorescein conjugated alpha-bungarotoxin were used to detect nicotinic receptors and anti-GAD for neuronal terminals. Results: It was observed the presence of one axon for each end-plate and glial cells spread over a branched axon. The nicotinic receptors clustered in the neuromuscular junction, neuronal terminals and large oval nucleus were detected. Conclusions: These observations suggest that the maturation of the neuromuscular junctions of the masseter muscles in the human fetuses has already begun at the 12-th week of gestation.

Corresponding author: Wilfredo Molina, DDs, MSc, PhD, e-mail: wjmw55@hotmail.com

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20. Urinary bladder diverticulum and its association with malignancy: an anatomical study on cadavers

Prakash, T. Rajini, Ajay Kumar Bhardwaj, Jayanthi V, P. Kalyani Rao, Gajendra Singh

Present work was directed to study the prevalence and anatomical basis of diverticulum formation and its association with malignancy inside the urinary bladder on cadavers. Urinary bladder diverticulum and its complications including malignancy has been reported by different authors based on their study on radiological findings and endoscopy. Present study was undertaken on cadavers to meet the aforementioned objectives. Thirty properly embalmed cadavers (19 males and 11 females) of different ages were dissected. Sagittal section of pelvis was studied. Urinary bladder was incised to expose the interior and it was examined for the presence of diverticulum (including number and location). Detailed history of the cause of death of cadavers with diverticulum was studied to determine how many of them suffered from urinary bladder diverticular carcinoma. 23.4% cadavers (31.6% males and 9.1% females) showed presence of urinary bladder diverticulum. The location of the diverticulum in all the cadavers was on superior and lateral side of the ureteric opening on the posterior surface of the urinary bladder. Diverticulum of one male cadaver aged 74 years was complicated by malignancy. Our study observed greater prevalence of diverticulum formation as compared to previous reports. In the present work, 14.3% diverticulum of the urinary bladder showed malignant change, which is more than earlier reports in the literature. Urinary bladder diverticulum should neither be neglected nor ignored. Appropriate early treatment (including the cause) of the diverticulum should be undertaken to avoid complications like malignancy which will finally ensure longevity.

Corresponding author: Prakash, Associate Professor, MD, e-mail: prakashrinku@rediffmail.com, prakash_sinha2005@yahoo.com

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21. Palmar dermatoglyphics in carcinoma breast of Indian women

N. S. Sridevi, C. R. Wilma Delphine Silvia, Roopa Kulkarni, C. Seshagiri

The present study was planned to assess the relationship of palmar dermatoglyphic patterns of hands in women with breast cancer and or at risk for developing breast cancer. This study was conducted on 100 histopathologically confirmed breast cancer patients in women and their digital dermatoglyphic patterns were studied to assess their association with the type and onset of breast cancer. Simultaneously 100 age-matched controls were also selected with no self or familial history of a diagnosed breast cancer and the observations were recorded. The differences of qualitative (dermatoglyphic patterns) data were tested for their significance using the chi-square test, and Student's t-test was used for quantitative (ridge counts and pattern intensity index) data analysis. The results of the study indicated statistically significant changes in finger ridge count and fingertip pattern in cases of carcinoma breast as compared to the control group. Palmar dermatoglyphics is simple, inexpensive, anatomical and non-invasive and may be used as a reliable indicator for screening of high-risk population in developing country like India, for early detection and early therapy, thus reducing the morbidity and mortality in cases of carcinoma breast.

Corresponding author: N. S. Sridevi, Assistant Professor, MS, e-mail: widel@rediffmail.com, sakshisri@rediffmail.com

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22. An anatomical and clinical insight on brachialis with emphasis on portal's muscle

Rajanigandha Vadgaonkar, Rajalakshmi Rai, S. R. Nayak, Sujatha D'Costa, Vasudha Saralaya, Dhanya

There have been conflicting descriptions regarding the anatomy of portal's muscle in the literature. The purpose of the present study seeks to clarify the presence, morphology, and potential function of this muscle in order to refine surgical techniques around the elbow. Forty-eight formalin fixed upper extremities were dissected and observed for attachments of brachialis meticulously and particularly over the anterior elbow joint capsule with special emphasis to the anatomical relation of the deeper fibers to the joint. It was found that there were varying patterns of muscular attachments over the anterior joint capsule with majority of the fibers of brachialis simply passing superficial to the joint capsule. The highest concentration of fibers was noted on the inferior part of the joint capsule, which was attached via connective tissue. These fibers were the deepest fibers of brachialis muscle that had no affect on the joint capsule following tension. Knowledge of this muscle may help the surgeons who operate in the elbow region to be tension free in preserving such fibers of clinically less importance.

Corresponding author: Rajalakshmi Rai, Senior Lecturer, e-mail: rajalakshmi.rai@manipal.edu

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23. Prostatic blue nevus

Denisa Anderco, Elena Lazar, Sorina Taban, Fl. Miclea, Alis Dema

We report the case of a 69-year-old patient with no significant personal urological history. The clinical and ultrasound examination revealed a prostatic gland with increased volume and homogenous appearance. After transurethral resection, multiples gray-brown-blackish prostatic chips were obtained, which could be confused with a malignant melanoma. The histological routine examination in conjunction with the histochemical (Fontana-Masson) and immunohistochemical (S100, HMB45) reactions established the diagnosis of prostatic blue nevus. The presence of melanin in prostatic tissue is an unusual aspect, being encountered three distinct lesions: blue nevus, melanosis and malignant melanoma. Recognition and correct classification of each of these three entities is fundamental, concerning the clinical and prognosis implications.

Corresponding author: Denisa Anderco, MD, PhD candidate, e-mail: denisa_dobre@yahoo.com

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24. Plaque-type morphea in children

Ligia Stanescu, Alina Valcea, Carmen Florina Popescu, Carmen Elena Niculescu, O. Ciobanu, G. Calin

We present the case of a girl, aged 8-year-old, with a history of acrocyanosis and repeated respiratory infections with beta-hemolytic streptococcus, which was consulted for the presence of skin lesions in the right buttock area. Clinical examination showed, in the right buttock region, an oval plaque with a diameter about 12 cm, hard, well defined, with irregular outline. The biopsy was performed and it revealed typical aspects of plaque-type morphea. The epidermis was mostly atrophic, with areas of ridge reduction; an important proliferation of collagen fibers within superficial and deep dermis and an abundant lymphocytic inflammatory infiltrate throughout the dermal thickness reaching hypodermic level and infiltrating it. General treatment consisted of antibiotics; vitamin E; local treatment with topical cortisone; analogues of vitamin D3 to which we associated topical adjuvants with repairing and healing role applied to the biopsied area. Evolution was favorable after three months of treatment, with obvious improvement of skin lesions; skin became more elastic and the purple red contour ring disappeared.

Corresponding author: Ligia Stanescu, Associate Professor, MD, PhD, e-mail: ligstanescu@yahoo.com

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25. Treatment of a mandibular canine abutment with two canals

Oana Cella Andrei, Ruxandra Margarit, Luminita Daguci

Human mandibular canines do not present an internal anatomy as simple as could be expected; there are such canines with a single root and two canals, two roots or fused roots. The existence of mandibular canines with more than one root canal is a fact that clinicians ought to keep in mind, in order to avoid failure during endodontic treatment. In spite of the low incidence of lower canines with one root and two canals, this possibility cannot be forgotten, in as much as the presence of a second canal in these teeth leads to difficulties in endodontic treatment. The precise knowledge of the dental endocanalicular system's anatomy is essential in the success of the root canal therapy, because the failure to detect the accessories canals and the incomplete radicular obturation leads to the infection of the periapical space, which will ultimately result in the loss of the tooth. The long-term success of the prosthodontic treatment depends directly on the quality of the endodontic treatment realized on the abutment teeth. The mandibular canine is very important as abutment for any type of prosthetic restoration. This article presents a clinical case of a canine tooth which displays a radicular morphology with two canals, which leads us to conclude that such anatomical variations on human teeth can also occur in our country as much as described in the international literature and cannot be overlooked when treating the teeth.

Corresponding author: Oana Cella Andrei, Lecturer, MD, PhD, e-mail: cella.andrei@gmail.com

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26. Coexisting of aortic arch variation of the left common carotid artery arising from brachiocephalic trunk and absence of the main branches of right subclavian artery: a review of the literature

Ozlen Karabulut, Kenan Iltimur, M. Cudi Tuncer

The variations in the aortic arch and its branches are of surgical interest. Many anomalies of the aortic arch and great vessels are uncovered as serendipitous findings on imaging studies, in the anatomy laboratory, or at surgery. A 56-year-old woman had an arch angiogram as part of an evaluation for cardiovascular disease. A two-vessel left aortic arch was identified consisting of the brachiocephalic trunk and left subclavian artery. In this study, we present a case of the left common carotid (LCC) artery arising from the brachiocephalic trunk (BT) and absence of the main branches of right subclavian artery in her angiographic imaging findings. There is no previous report about LCC artery arising from BT and absence of the main branches of right subclavian artery in the same person.

Corresponding author: Mehmet Cudi Tuncer, Associate Professor, MD, PhD, e-mail: drcudi@hotmail.com

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27. Invasive thymoma

I. Donoiu, R. I. Radu, Alina Giuca, M. Popescu, D. D. Ionescu

Thymomas are rare tumors of the thymic epithelium with a broad spectrum of morphological and clinical features. Despite a benign histological appearance, it can invade nearby structures or metastasize. The majority of patients are asymptomatic, but some may present with paraneoplastic syndromes such as myasthenia gravis, red cell aplasia, or hypogammaglobulinemia. Various staging systems of thymomas have been defined based on the degree of invasiveness. According to the WHO Classification, there are six histologic types of thymic epithelial tumors. The most important prognostic factor is the stage according to Masaoka's system. We report a case of invasive thymoma diagnosed incidentally in a patient with cardiovascular risk factors referred to the cardiologist with suspected thoracic aorta aneurism.

Corresponding author: Ionut Donoiu, MD, e-mail: i.donoiu@gmail.com

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28. Supratentorial pilocytic astrocytoma in children

Carmen Elena Niculescu, Ligia Stanescu, M. Popescu, D. Niculescu

Brain tumors hold second place in tumoral pediatric pathology and have a complex etiopathogeny. The authors describe the case of a child aged 2 years and 4 months with increased intracranial pressure, symptomatology accompanied by rapid deterioration of general condition. Head CT imaging examination showed intra-nevraxial replacement space process, supratentorial. Histopathological examination revealed the typical grade I pilocytic astrocytoma. Time of diagnosis and surgical intervention is essential for further evolution and prognosis.

Corresponding author: Carmen Elena Niculescu, Associate Professor, MD, PhD, e-mail: niculescudragos@yahoo.com

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29. Oral manifestations in Apert syndrome: case presentation and a brief review of the literature

Andrada Soanca, Diana Dudea, H. Gocan, Alexandra Roman, B. Culic

Background: The present paper describes the oral manifestations in a 16-year-old boy previously diagnosed with Apert syndrome. Patient and Methods: The extraoral and intraoral pathological findings were recorded. The following intraoral parameters were recorded: plaque and calculus deposits, dental caries, periodontal status, malpositions, and occlusion. For the upper anterior teeth, dental shade was recorded, using a dental spectrophotometer. The corresponding diagnostics were established. A treatment plan was established and discussed with the child's parents. Results: The dysmorphic characters were obvious, including acrocephaly, prominent forehead, hypoplastic midface, hypertelorism, short nose. The intraoral features revealed a bifid uvula and Byzantine-arch palate associated with lateral swellings of the palatine processes, one on either side of the middle miming a pseudocleft in the midline. Heavy dental plaque, dental calculus, congestion and swelling of the gingiva and periodontal pseudopockets associated with anterior teeth were recorded. Dental caries on anterior and posterior teeth were present. Severe maxillary dental crowding associated with the rotation of central incisors and the palatal position of second bicuspids and the malposition of the mandibular anterior teeth were observed. No intrinsic discoloration of the dental structure was recorded. Severe anterior and posterior open bite and crossbite were observed. Other signs were represented by syndactyly involving partial fusion of the fingers and toes. Also, mild mental deficiency was recorded. Conclusions: The information and the strong motivation of the parents regarding the necessity of the treatment and the extensive use of home prevention methods are essential to control oral conditions in these patients.

Corresponding author: Alexandra Roman, MD, e-mail: veve_alexandra@yahoo.com

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30. Multiple variations in the branching pattern of the abdominal aorta

A. Raikos, G. K. Paraskevas, K. Natsis, A. Tzikas, S. N. Njau

We report on a unique clinically and surgically significant case of multiple abdominal aorta variations. Specifically, the left inferior phrenic, left gastric and splenic artery arose in common from the left aspect of the aorta constituting a common phrenogastrosplenic trunk, while the common hepatic artery originated separately from the midline of the anterior aspect of the aorta just inferiorly to the trunk. An accessory right hepatic artery arises from the right-anterior aspect of the abdominal aorta adjacent to superior mesenteric artery origin. On the left side, two renal arteries were observed. Moreover, the left gonadal artery exhibited a high origin, arising inferiorly to the upper left renal artery. We discuss about the embryological development of abdominal aorta arterial abnormalities and we attempt to sort the noticed variations according to existing classification in the literature. It is highlighted that the thorough knowledge of these arterial variations is important for the success of upper abdomen surgical operations such as liver and kidney transplantation, kidney preservation, abdominal aorta related vascular surgery, treatment of hepatocellular carcinoma by transcatheter arterial chemoembolizations as well as imaging interpretation of the region. Preoperative selective angiography or other abdominal aorta imaging studies are helpful for arterial variation demonstration and a precious tool for appropriate surgery planning.

Corresponding author: Athanasios Raikos, Research Fellow, MD, e-mail: araikos@auth.gr

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31. Ectopic kidney with malrotation and bilateral multiple arteries diagnosed using CT angiography

Delia Elena Zahoi, G. Miclaus, Aurora Alexa, Dorina Sztika, Agneta Maria Pusztai, Mioara Farca Ureche

Right renal ectopia with malrotation was seen on a CT angiography in a 64-year-old male patient. Bilateral triple renal arteries were also revealed: one main (superior) renal artery and two accessory arteries (middle and inferior), all originating in the abdominal aorta. The renal arteries are disposed symmetrically. The main arteries and the accessory ones are of equal caliber. Simple renal ectopia is a congenital malformation with an incidence of 1-2 cases in 1000 births; of these, only one of 10 cases is diagnosed. Like our case, many such cases are diagnosed by accident, during investigations of causes that have no connection with renal ectopia. Variations in kidney position and renal vascular variants are very important clinically, for both the complications they may generate and the technical difficulties of certain surgical interventions. CT angiography is a minimally invasive method that allows the identification of malformations or anatomic variations, providing accurate information on position, size and anatomic ratios, which are very useful in diagnosing and treating various affections.

Corresponding author: Delia Elena Zahoi, Professor, MD, PhD, e-mail: dzahoi@umft.ro

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32. Anomalous branching pattern of the external carotid artery: a case report

Mamatha T, Rajalakshmi Rai, Latha V. Prabhu, Gavishiddappa A. Hadimani, Jiji PJ, Prameela MD

Variations in the branching pattern of the external carotid artery (ECA) are well known and documented. The variation in the present case was compared with those reported before. An anomalous unilateral variation in the branching pattern of the left ECA was observed in a male embalmed cadaver. In this case, the ECA gives a direct branch directly to the submandibular salivary gland, a thyrolingual trunk, an auriculo-occipital trunk and a facial artery with an unusual course. The embryogenesis of such a combination of anomalies is not clear, but the anatomic consequences may have important clinical implications. Anatomical knowledge of the origin, course, and branching pattern of the external carotid artery will be useful to surgeons when ligating the vessels during head and neck surgeries.

Corresponding author: Rajalakshmi Rai, e-mail: rajalakshmi.rai@manipal.edu

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