Vol. 52 No. 2, April-June 2011

1. New mediators of vascular damage in dialysed patients

I. A. Checherita, C. David, L. Stoica, P. Popescu, A. Ciocalteu, I. Lascar

Cardiovascular events are the main causes of mortality in dialysed patients. Traditional risk factors such as hypertension, aging, smoking, diabetes, and abnormal lipid metabolism does not fully explain the high frequency of cardiovascular disease in renal patients, indicating that some other distinct pathogenesis may be involved. Vascular calcification have been associated with high cardiovascular morbidity and mortality in chronic kidney disease (CKD) patients. It is an active process that resembles osteogenesis, regulated by bone proteins and osteoblast-like cells. Elements involved in the pathogenesis are: the risk factors that initiates the process, the promoters released and overexpressed and the dysregulation of the inhibitor factors of extraskeletal calcifications. Although researches in the past decade have greatly improved our knowledge of the multiple factors and mechanisms involved in vascular calcification, many questions remain unanswered.

Corresponding author: Ionel Alexandru Checherita, Junior Assistant, MD, PhD student, e-mail:

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2. Colorectal cancer and the 7th revision of the TNM staging system: review of changes and suggestions for uniform pathologic reporting

Fl. Obrocea, Maria Sajin, Elena Cristina Marinescu, D. Stoica

Colorectal cancer (CRC) is a neoplastic disease with a continuously growing incidence in Romania and throughout the world. Although the surgery remains the first line treatment for most of the cases, newly discovered targeted molecular therapies - effective for some patients, but with various side effects and significant financial burden for the national health systems - requires not only stratification of patients in prognostic groups but also evaluation of some non-anatomic factors with major impact on the prognosis and therapeutic strategy. The AJCC/UICC TNM staging system, in his 7th revision, effective for cases diagnosed on or after January 1, 2010, responds to these needs. On the other hand, the role of the pathologist is increasing in terms of workload and amount of information to be included in the pathology report in order to deliver a personalized diagnosis. There are concerns worldwide regarding relevance, validity and completeness of pathologic reporting of CRC in the absence of a uniform reporting format. Therefore, suggestions for a standardized pathology report of CRC are made, based on TNM 7 and recent, up-to-date conclusive published data.

Corresponding author: Florin Obrocea, MD, e-mail:

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3. Evaluation of proliferation potential in thyroid normo-/hypofunctioning and hyperfunctioning nodules

Marioara Cornianu, V. Stan, Elena Lazar, Alis Dema, Ioana Golu, Sorina Taban, Mihaela Vlad, Alexandra Faur, F. Varcus, F. Babau

Introduction: Thyroid follicular adenomas (FA) and adenomatous thyroid nodules (AN) - lesions that are frequently found in areas with iodine deficiency, can be normo-/hypofunctioning (scintigraphically cold - SCN) or hyperfunctioning (scintigraphically hot - SHN) nodules. Aim: Evaluation of proliferation potential in thyroid nodules on tissue samples obtained at surgery from euthyroid patients clinically diagnosed with SCN and from patients with thyroid hyperfunction and SHN. Materials and Methods: We investigated the proliferation activity estimated by assessing PCNA and Ki-67 proliferation markers in 20 SCN (eight FA and 12 AN) and 16 toxic nodules (six hyperfunctioning FA and 10 toxic multinodular goiters), on formalin-fixed and paraffin-embedded tissue samples, 4-5 micro-m thick; we used the immunohistochemical technique in LSAB system (DAB visualization) with anti-PCNA (PC10) and anti-Ki-67 (MIB-1) monoclonal antibodies. For each case, we calculated the proliferation index PI-PCNA and PI-Ki-67. The dates were statistically evaluated using the t-unpaired test. Results: We observed a higher PI-PCNA in thyroid nodules than in the normal surrounding thyroid tissue, with statistically significant values for FA (14.3% vs. 3.8%; p<0.029) and also for AN (8.36% vs. 1.24%; p<0.001). The mean PI-Ki-67 in nodules vs. surrounding thyroid tissue was 1.64% vs. 1.10% in FA (p<0.35) and 1.07% vs. 0.51% in AN (p>0.05). We also noted: (1) significantly higher PI-PCNA values (p<0.01) in FA (14.03%) than in AN (8.36%), as compared to statistically insignificant values for Ki-67 (1.64% vs. 1.07%; p>0.05); (2) increased proliferation rate (p<0.01) in thyroid nodules with aspects of lymphocytic thyroiditis (LT) (PI-Ki-67 was 1.21%) as compared to nodules without LT (PI-Ki-67 was 0.12%); (3) a mean PI-PCNA of 8.5% and PI-Ki-67 of 4.61% in toxic thyroid nodules (TTN) vs. 3.01% and 1.5% in normal surrounding thyroid, respectively. Conclusions: The clinical expression of SCN is the consequence of increased thyrocyte proliferation in the nodules; the increased proliferative potential of TTN thyrocytes is a common feature of nodules, independent of their histopathological characteristics.

Corresponding author: Marioara Cornianu, MD, e-mail:

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4. Histopathological and immunohistochemical features of gastrointestinal stromal tumors

Emoke Fulop, Simona Marcu, Angela Borda, C. Moldovan, E. F. Fulop, Andrada Loghin, Z. Pavai

Gastrointestinal stromal tumors (GISTs) are the most frequent mesenchymal tumors of the gastrointestinal tract. Major advances in their definition and classification and the understanding of their molecular mechanisms have recently been made. These advances have become a model of targeted therapy in oncology. The diagnosis of GISTs relies on histological arguments - proliferation of spindle cells, seldom of epithelioid cells or both spindle and epithelioid cells - and on immunohistochemical arguments - expression of CD117 usually associated with CD34 expression. The evaluation of the prognosis is essential and based on a simple algorithm using two prognostic parameters, tumor size and mitotic index. The aim of this paper is a complex histopathological assessment, using both classic and modern (immunohistochemistry) techniques, of the GISTs comprised in the study. GISTs occur mainly in older adults (median age 60-69 years), anywhere along the gastrointestinal tract but also retroperitoneal. Most of them were nodular (75%), tumor necrosis and mucosal ulceration being the most frequent encountered secondary alterations; these modifications proved to be significantly correlated with large tumor size and high malignancy. Immunohistochemical evaluation revealed that 77 (97%) cases of GISTs presented a positive reaction for CD117, 50 (63%) cases were positive for CD34, 19 (24%) were positive for SMA and only 10 (13%) were positive for S100. Immunohistochemical evaluation remains an important tool of pathology in the diagnosis of GISTs, in the differential diagnosis from other gastrointestinal mesenchymal tumors and represents the gold standard for diagnosis of these tumors and an eligibility criterion for imatinib therapy.

Corresponding author: Emoke Fulop, University Assistant, MD, PhD, e-mail:

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5. Pulmonary venous compartment of the airways circulation

I. Mindrila, O. M. Marginean, B. Capitanescu, D. Pirici, P. R. Melinte, R. Stanescu, G. A. Guja

Bronchial circulation has three components: a systemic arterial component represented by the bronchial arteries; a pulmonary venous component represented by the pulmonary veins; and a systemic venous component represented by the bronchial veins. We have used vascular casting, microscope dissection coupled with tracers and light microscopy to define the detailed anatomy of the pulmonary venous compartment of the bronchial circulation. We have found that the extrapulmonary drainage territory of the pulmonary veins correlate with the forming pattern of the right superior pulmonary vein. In the case of a large apical venous trunk, pulmonary veins drain the venous blood of the main bronchia, terminal portion of the trachea and of the tracheobronchial lymph nodes. In the case of the systemic venous drainage of the extrapulmonary airways, we constantly found a pulmonary component which drains the venous blood from the subcarinal lymph nodes and the medial side of the main bronchia.

Corresponding author: Ion Mindrila, Associate Professor, MD, PhD, e-mail:

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6. Stage pT3a of renal clear cell carcinoma: do tumors with sinus fat involvement behave the same as those with perinephric fat involvement?

S. Chaves Portela, D. Santos-Arrontes, Maria J. Fernandez-Acenero, J. Garcia Gonzalez, P. Paniagua

Introduction: In this report, we review our series of patients with pT3a clear cell renal carcinoma (CCRC) and comment on their outcome. Materials and Methods: We have reviewed 260 cases of CCRC operated in the Mostoles General Hospital, Madrid, between 2000 and 2004. We have found 30 cases with pT3a tumors. Eleven of them were invading the perinephric fat, nine were invading the renal sinus fat and ten were pT3a locally but showed metastasis at the moment of diagnosis (cM1, TNM stage IV). We have analyzed the prognostic influence of histopathological parameters (vascular invasion, size, Fuhrman grade) and also immunohistochemical ones (p53, cyclin D1, proliferation index with Ki67, bcl-2 and vascular density with CD34). Results: Only six of 10 patients with perinephric fat involvement died of disease compared with all the patients with sinus fat involvement, suggesting a worse prognosis for the latter. However, this difference did not reach statistical significance, probably due to the small number of cases. Of all the clinical, histological and immunohistochemical factors analyzed, only cyclin D1 was a strong indicator of worse prognosis in pT3a CCRC (p=0.02). We could not show any statistically significant relation between vascular density and prognosis. Vascular invasion was the only histological parameter that showed a trend toward significance (p=0.09). Conclusions: Sinus fat involvement might be underestimated in some series. A protocol for nephrectomy specimen handling could improve the detection rate of sinus fat involvement and allow the performance of randomized prospective studies to determine whether these tumors behave similarly.

Corresponding author: Maria J. Fernandez-Acenero, MD, PhD, e-mail:

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7. Diabetes mellitus type 1 induces dark neuron formation in the dentate gyrus: a study by Gallyas' method and transmission electron microscopy

Sh. Ahmadpour, H. Haghir

Background: Diabetes mellitus type 1 is a chronic endogenous stressor. We investigated the effects of a diabetes mellitus type 1 on dark neuron formation in granular layer of dentate gyrus. Materials and Methods: Diabetes was induced by a single intraperitoneal (IP) injection of streptozotocin (STZ) at a dose of 60 mg/kg dissolved in saline. Control animals were received only saline. In the end of eight weeks, the brains were removed and hippocampi studied by Gallyas' method and transmission electron microscopy. Results: The comparison between the rate of dark neurons in diabetic group (223+/-25) and of control (5.75+/-4.34) showed significant level of difference (p<0.05). Ultrastructurally dark neurons showed apoptotic death criteria namely: dark and electron dense appearance, chromatin condensation, margination and clumping. Conclusions: Present results suggest that STZ-induced diabetes accelerates dark neuron formation with apoptotic criteria in granule layer of dentate gyrus.

Corresponding author: Shahriar Ahmadpour, Assistant Professor, e-mail:

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8. The diagnostic value of VEGF expression in the renal parenchyma tumors

Flavia Baderca, Aurora Alexa, Rodica Lighezan, D. Izvernariu, M. Raica

Tumor angiogenesis emerged as an important concept in cancer therapy over two decades ago, and was extensively studied by the discovery of VEGF family members. VEGF, also known as vascular permeability factor, is a generic name for VEGF-A, which is one of the members involved in angiogenesis. VEGF is the most important angiogenic factor, with significant effects on tumor angiogenesis. Tumor expression of VEGF was not the first angiogenesis indicator, but a growing number of studies have demonstrated that VEGF could be a prognostic factor, independent even from microvascular density, which is increased by its expression. Renal parenchyma tumors are a heterogeneous group of malignancies, difficult to classify or monitor, which prompts for the assessment of novel markers useful for the investigation of tumor histogenesis or prognostic assessment. VEGF expression in renal parenchyma tumors is poorly studied, with most of the articles published so far focusing on antiangiogenic usage in renal carcinoma therapy. The aim of this study is to detect the expression pattern of VEGF in renal parenchyma tumors by immunohistochemistry.

Corresponding author: Flavia Baderca, Lecturer, MD, PhD, e-mail:

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9. WITHDRAWN: Alterations in expression of cartilage-specific genes for aggrecan and collagen type II in osteoarthritis

B. A. Jalba, C. S. Jalba, Anca-Daniela Vladoi, F. Gherghina, E. Stefan, M. Cruce

Article withdrawn by publisher.

Corresponding author: Bogdan-Alexandru Jalba, MD, PhD student, e-mail:

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10. Practical value of the complex analysis of sentinel lymph nodes in colorectal carcinomas

Simona Gurzu, I. Jung, T. Bara, T. Bara Jr, Z. Szentirmay, L. Azamfirei, Erika Toth, M. Turcu, Em. Egyed-Zsigmond

Background: Despite modern factors, which seem to predict outcome, lymph node (LN) status remain the main prognostic factor, which also shows the need for complex oncotherapy in colorectal carcinomas (CRC). Sentinel lymph nodes (SLNs) mapping is a very controversial method, which can increase the number of identified LN. Materials and Methods: In 28 patients who underwent surgical intervention between December 2009 and December 2010, we performed in vivo SLNs mapping followed by ex vivo examination at 1, 10, and 48 hours. All blue nodes were separately included. In cases without LN metastases (pN0) five multilevel sections and immunohistochemical stain with cytokeratin 20 were performed in SLNs. Results: Two cases were excluded because they were in pT4 stage. In one case the diameter of lymph nodes was about 10 mm and we obtained a false negative result (negative SLNs with positivity in the non-SLNs). From the other 25 cases, 13 do not presented LN metastases or micrometastases, nine had metastases only in the SLNs and the other three in both SLNs and non-SLNs. Mean identified number of LNs was 15. The blue dye intensity increased after formalin fixation and some nodes with metastases were blue stained only after 10 hours. Conclusions: SLNs mapping is a simple and inexpensive technique, which can improve the management of CRC. All in vivo and ex vivo blue LNs should be considered SLNs. Ultrastaging of SLNs is an expensive method, with uncertain results. High diameter of LNs seems to be an exclusion criterion for SLNs mapping.

Corresponding author: Simona Gurzu, Assistant Professor, MD, PhD, e-mail:

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11. Could stored blood transfusions (SBT) alter the mechanisms implied in wound healing, in burned patients?

M. C. Neamtu, Alina Parvu, H. Parvanescu, L. R. Neamtu, Maria Vrabete

Several years ago, researchers reported several complications produced after blood transfusions such as transfusion reactions, the transmission of a variety of infectious agents, etc. Recently, many authors appreciate that the stored blood transfusions (SBT) create an important damage for patients' life, because of oxygen metabolism disturbances, induced earlier, after three repeated transfusions and maintained longtime after. Our study proposed to note the consequences of SBT on wound healing, in burned patients, who were submitted to skin grafting and remained in hospital for a long period. We tried estimate the pathophysiological mechanisms implied in microcirculation's failure, microvascular systemic deficiency and death. Results: Critically patients receiving SBT repeated frequently (six times/monthly for skin grafting) have an oscillatory outcomes depending by the reactivity of their biological terrain, as reflected by a several parameters we have measured. Conclusions: SBT administered as a restrictive transfusions to the patients with hemoglobin values <8 g% and hematocrit <35% has good effects on wound healing evolution.

Corresponding author: Marius Cristian Neamtu, MD, e-mail:

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12. Distribution of sympathetic fiber areas in the sensory nerves of forearm: an immunohistochemical study in cadavers

S. Chakravarthy Marx, P. Kumar, S. Dhalapathy, C. Anitha Marx

Purpose: Secondary to peripheral nerve injuries, involvement of sympathetic fibers complications such as Complex Regional Pain Syndrome (CRPS) have been reported. There are no reports available in the distribution of the sympathetic fibers/areas of sensory nerves in the forearm. Materials and Methods: The present study aim is an attempt to find the distribution of sympathetic fibers in the anterior branch of medial antebrachial cutaneous nerve of forearm (AMACN), lateral antebrachial cutaneous nerve of forearm (LACN) and superficial branch of radial nerve (SBRN) at cubital fossae. We have studied on 17 fresh human cadaveric AMACN, LACN and SRBN samples. Frozen sections of these nerves were processed by immunohistochemical (tyrosine hydroxylase) method for sympathetic fibers. Results: Sympathetic fibers area (Asym) was found to be more in SBRN when compared to AMACN and LACN. The comparison of the sympathetic index (SI = sympathetic fibers area / total fascicular area of the nerve) between AMACN and LACN (p-value <0.001), AMACN and SBRN (p-value <0.001), LACN and SBRN (p-value <0.001) were statistically significant. Sympathetic index (SI) for SBRN was more when compared to AMACN and LACN. SBRN had maximum percentage (5.16%) of Asym when compared with LACN and AMACN. Conclusions: Sympathetic fibers area (Asym), sympathetic index (SI) and percentage of sympathetic fibers area (Asym %) were found to be more in SBRN when compared with AMACN and LACN. These results of the study might help to explain sympathetic system-related diseases in the area of distribution of AMACN, LACN and SBRN.

Corresponding author: S. Chakravarthy Marx, PhD, e-mail:

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13. CD105/Ki67 double immunostaining expression in liver metastasis from colon carcinoma

Raluca Amalia Ceausu, Anca Maria Cimpean, Pusa Gaje, Simona Gurzu, I. Jung, M. Raica

The liver is the most common and critical site for the development of colon cancer metastases. Tumor angiogenesis in liver metastasis from colon carcinoma is a controversial subject. Liver microenvironment, immunophenotypical and morphological particularities of hepatic vessels are only few aspects, which establish difficulties in quantification of tumor vascularisation from liver metastasis. The aim of this work is to study the distribution of CD105 positive vessels and the proliferation rate of endothelial cells from liver metastasis of colon carcinoma based on double immunostaining CD105/Ki67. In liver metastasis from well-differentiated adenocarcinoma we found a high number of CD105+/Ki67- vessels. On the other hand, in liver metastasis from poorly differentiated adenocarcinoma we noticed rare CD105+/Ki67+ vessels. It is hypothesized that neoangiogenesis of liver metastasis is performed through intussusceptive mechanism rather than sprouting and could be supported by the presence of kissing phenomenon, CD105 positive transcapillary pillars and the absence of endothelial cells proliferation in this vessels. We conclude that in liver metastasis principal mechanism of neovascularisation formation is based on intussusception.

Corresponding author: Raluca Amalia Ceausu, MD, PhD student, e-mail:

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14. The arthroscopy-histological criterion link in the result's estimation of the endoscopic treatment by resection of the knee's meniscus lesions

D. Niculescu, Carmen Niculescu, Maria Stoica, Ligia Stanescu, D. Grecu, I. E. Plesea, S. D. Enache

The authors present the results of a statistical, clinical, imaging X-ray and optical microscopic studies of some lesions of knee's meniscus, the arthroscopy allowing this structure's biopsy during the endoscopic procedures of resection. These histological criterions are very important estimation factors of long-term results of these techniques, often the microstructure looking different to the appearing normal macroscopic aspect.

Corresponding author: Dragos Niculescu, MD, e-mail:

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15. Morphologic, morphometrical and histochemical proprieties of the costal cartilage in children with pectus excavatum

V. L. David, D. A. Izvernariu, C. M. Popoiu, Maria Puiu, E. S. Boia

Pectus excavatum (PE) is the most frequent anterior chest deformity occurring in approximately one of 1000 live births. Despite the excellent achievements in the treatment of the disease, the etiology of PE is yet to be clarified. It is believed that the cause for PE is an intrinsic costal cartilage abnormality leading to an overgrowth of the cartilage, which pushes the sternum backward. Several histological studies revealed contradictory results and failed to identify a clear structural abnormality of the costal cartilage responsible for the apparition of PE. In this article, we focused on identifying the microscopic disturbances of the costal cartilage in patients with PE. We obtained cartilage samples from 29 children with PE and 18 control cartilage samples. The samples were subjected to morphologic, morphometrical and histochemical assess. The results indicate a young, immature pattern of the cartilage matrix with a normal cell/matrix ratio. These results sustain the theory that the cause of PE is to be found inside the costal cartilage and the most plausible cause is a global overgrowth of the costal cartilage.

Corresponding author: Vlad Laurentiu David, MD, e-mail:

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16. Endometrial carcinomas: correlation between ER, PR, Ki67 status and histopathological prognostic parameters

Sidonia Catalina Stoian, Cristiana Simionescu, Cl. Margaritescu, A. Stepan, M. Nurciu

We present a retrospective histopathological study that included a total of 22 endometrial carcinomas, from patients that were operated in the Obstetrics and Gynecology Clinics of the Emergency County Hospital of Craiova. This current study investigates these cases in order to assess the prognostic value of the correlations between the expression of estrogen and progesterone receptors, Ki67 expression and the histological stage, tumor stage, the degree of myometrial and vascular invasion. The study showed that estrogen and progesterone positive receptors correlate significantly with early stage and well differentiated tumors. The invasion of more than half the thickness of the myometrium and the vascular invasion were associated with decreased expression of the analyzed receptors and an increased proliferation index.

Corresponding author: Sidonia Catalina Stoian, MD, PhD candidate, e-mail:

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17. Power Doppler sonography, a non-invasive method of assessment of the synovial inflammation in patients with early rheumatoid arthritis

Fl. Vreju, M. Ciurea, Anca Rosu, Anca Musetescu, D. Grecu, Paulina Ciurea

Objective: To detect synovitis is important in both the diagnosis and outcome assessment of early rheumatoid arthritis. This study was meant to assess the validity and reproducibility of ultrasonography (US) as a mean of detection for the knee synovitis, by comparing US findings with clinical examination and histopathological findings in synovial membrane. Methods: The study group included 65 patients with early rheumatoid arthritis - below 12 months from the debut, naive for DMARDs, in whom demographic data - gender, age, disease duration, the number of tender and swollen joints, HAQ score (Health Assessment Questionnaire) and serum samples for CRP, RF, anti-CCP2 antibodies (ELISA, QUANTA LiteTM, CCP IgG, INOVA Diagnostics Inc, USA), VEGF (ELISA, VEGF2, DRG International, IRC, USA) determination were recorded. Disease Activity Score for 28 joints (DAS28) was calculated. PDS signal was scored from 0 to 3 according to the overall expression of PDS findings at the knees. A sample of synovial tissue was obtained in 35 patients during the arthroscopy, and the vascularisation of the synovial tissue was evaluated by immunohistochemistry and was analyzed qualitatively by a pathologist who was unaware of the PDS findings. Written, informed consent was obtained from each patient before entering the study. They all had active synovitis of the knee, ultrasonographically confirmed, with the identification of the target biopsy sites. The study was approved by the Ethics Committee of the University of Medicine and Pharmacy of Craiova. Results: Angiogenesis was evaluated and quantified by immunohistochemical evaluation of synovial VEGF, one of the most specific endothelial growing factors, that proved to correlate significantly with the serum levels of VEGF, DAS28 as well as with the power Doppler sonography (PDS) score. Conclusions: The statistical analysis of the data showed that PDS could be used as non-invasive marker with predictive value regarding synovial inflammation and disease progression in early forms of the disease as well as a useful method in the assessment of the therapeutic response.

Corresponding author: Florentin Vreju, Teaching Assistant, MD, PhD, e-mail:

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18. Relationship between sperm chromatin status and ICSI outcome in men with obstructive azoospermia and unexplained infertile normozoospermia

M. R. Sadeghi, N. Lakpour, H. Heidari-Vala, Mahshid Hodjat, N. Amirjannati, H. Hossaini Jadda, Sima Binaafar, M. M. Akhondi

This study was done to evaluate the effect of sperm source on chromatin integrity and ICSI outcomes. One hundred and thirteen samples containing epididymal aspirates of 57 obstructive azoospermic men and 56-ejaculated semen of normozoospermic men were included in this study. Sperm chromatin status was evaluated by Chromomycin A3 (CMA3), Aniline Blue (AB) and Toluidine Blue (TB). Fertilization rate and embryo quality were recorded. In epididymal group the percentage of sperms stained with AB, CMA3 and TB were significantly higher compared to ejaculate group while fertilization rate (60.6% vs. 74.04%) was significantly lower. However, embryo quality was not significantly different between two groups. In addition, abnormal sperm chromatin condensation and DNA fragmentation were not correlated with fertilization rate and embryo quality. Our results highlight the role of epididymis in sperm maturation and confirm that ICSI using ejaculated sperm is the gold standard for treatment of infertile men.

Corresponding author: Mohammad Mehdi Akhondi, PhD, e-mail:

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19. P16, c-erbB2 and Ki67 immunoexpression in urothelial carcinomas of the bladder

A. Stepan, Cristiana Simionescu, Cl. Margaritescu, Raluca Ciurea

The study included a total of 28 cases of urothelial carcinomas, which were analyzed histopathologically and immunohistochemically using anti-human p16, c-erbB2 and Ki67 antibodies and the LSAB/HRP work system. Histopathological analysis revealed the presence of urothelial carcinomas with different degrees of differentiation and invasion in the lamina propria or muscularis propria. The immunostain for p16, c-erbB2 and Ki67 was present at the nuclear and cytoplasmic level, respectively at membrane and nuclear level. Immunoreactions had quantified values, which were statistically correlated with the degree of differentiation in case of c-erbB2 or depth of invasion for p16. Tumor activity status and the risk of progression of bladder urothelial carcinomas can be assessed objectively using the antibody panel consisting of p16, c-erbB2 and Ki67.

Corresponding author: Alex Stepan, Assistant, MD, PhD candidate, e-mail:

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20. Age assessment from mandible: comparison of radiographic and histologic methods

D. P. Mohite, M. S. Chaudhary, P. M. Mohite, S. P. Patil

Age assessment is an integral and important aspect of forensic odontology. The use of long bones and teeth has been documented since decades. The aim of this study was to use both radiographic and histologic methods of age estimation and to determine which method gives a near actual age. Orthopantomograph (OPG) was used to study the radiographic changes and ground sections were made for histologic study. Of the various parameters studied, we concluded that the histologic parameters recorded ages, which were closer to the actual age. Of the histologic parameters, two to three parameters when combined were still better.

Corresponding author: Deepali Mohite, Senior Lecturer, MDS, PhD, e-mail:,

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21. Identification of different subtypes of breast cancer using tissue microarray

M. A. Munirah, M. A. Siti-Aishah, M. Z. Reena, N. A. Sharifah, M. Rohaizak, A. Norlia, M. K. M. Rafie, A. Asmiati, A. Hisham, I. Fuad, N. S. Shahrun, S. Das

Breast cancer may be classified into luminal A, luminal B, HER2+/ER-, basal-like and normal-like subtypes based on gene expression profiling or immunohistochemical (IHC) characteristics. The main aim of the present study was to classify breast cancer into molecular subtypes based on immunohistochemistry findings and correlate the subtypes with clinicopathological factors. Two hundred and seventeen primary breast carcinomas tumor tissues were immunostained for ER, PR, HER2, CK5/6, EGFR, CK8/18, p53 and Ki67 using tissue microarray technique. All subtypes were significantly associated with Malay ethnic background (p=0.035) compared to other racial origins. The most common subtypes of breast cancers were luminal A and was significantly associated with low histological grade (p<0.000) and p53 negativity (p=0.003) compared to HER2+/ER-, basal-like and normal-like subtypes with high histological grade (p<0.000) and p53 positivity (p=0.003). Luminal B subtype had the smallest mean tumor size (p=0.009) and also the highest mean number of lymph nodes positive (p=0.032) compared to other subtypes. All markers except EGFR and Ki67 were significantly associated with the subtypes. The most common histological type was infiltrating ductal carcinoma, NOS. Majority of basal-like subtype showed comedo-type necrosis (68.8%) and infiltrative margin (81.3%). Our studies suggest that IHC can be used to identify the different subtypes of breast cancer and all subtypes were significantly associated with race, mean tumor size, mean number of lymph node positive, histological grade and all immunohistochemical markers except EGFR and Ki67.

Corresponding author: M. A. Siti-Aishah, Professor, e-mail:

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22. Malignant melanoma of nasal cavity

S. Ciolofan, Elena Ionita, Carmen Aurelia Mogoanta, Florina Carmen Popescu, F. Anghelina, Luminita Chiutu, G. Stanciu

Introduction: Malignant melanoma rarely develops in the mucous membranes. Statistical data indicate that rhinosinusal mucosal melanoma was reported in less than 1% of all melanic tumors and in 2-8% of all cancers developed in the nasal fossae and sinuses. Due to reduce and non-specific symptoms and a high degree of invasion away, patients come for a medical expertise in advanced stages of the disease, which is leading to a poor prognosis. The average five-year survival is 20-30%. Patient and Methods: We present the case of a 65-year-old female patient coming from a rural environment, hospitalized for unilateral nasal obstruction and nasal mucosal changes of a blackish appearance on all of the walls. Results: The endoscopic examination revealed a matter and of a blackish appearance nasal mucosa along the whole length of the left nasal cavity (septum, turbinates, floor, ceiling). Presumptive diagnosis of melanoma led to the excision of inferior and middle turbinate mucosa, floor and ceiling mucosa and the excision of the nasal septum, keeping the columella and the posterior portion. Histopathological and mostly immunohistochemical exams confirmed the diagnosis of malignant melanoma. To determine the phenotype of tumor cells, it was evaluated their immunostaining for HMB-45, Melan-A, S-100, vimentin, cyclin D1 and CD44 markers. The patient followed oncologic treatment and radiochemotherapy, presenting a favorable evolution with the absence of loco-regional recurrence or distant metastasis 24 months postoperatively.

Corresponding author: Mircea-Sorin Ciolofan, Assistant Professor, MD, PhD, e-mail:

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23. Cardiac allograft vasculopathy in adult human recipients: a case series of seven patients and review of literature

O. S. Cotoi, H. Suciu, Anca Sin, M. Turcu, S. H. Morariu, Z. Szabolcs, Simona Stolnicu

Background: Chronic rejection (CR) also called cardiac allograft vasculopathy (CAV) is, besides infections and malignant tumors, the leading cause of death during the late period of post-heart transplant. Patients and Methods: In this paper, we present a series of seven cases with chronic post-transplant cardiac rejection in the light of our experience related to histopathological aspects, difficulties in diagnosing and survival time. Results: Our study comprises patients whose ages ranked at the time of transplant between 33 and 58 years, with a mean age of 47.71 years, the ratio between men and women being 6:1. Chronic rejection - cardiac allograft vasculopathy occurred in all seven patients comprised in this study, the earliest in the second year post-transplant (three patients), followed by the third year (one patient), the seventh and eighth year (one patient) and the latest survival period being over 11 years (one patient). Four out of the seven patients with chronic rejection events were preceded by episodes of acute cellular rejection. The most convincing indirect evidence of chronic rejection in endomyocardial biopsies were: ischemic events of the myocardiocytes and impaired microvascular network because of perivascular and interstitial fibrosis. Conclusions: Our study shows that the most important morphological factors correlated with the manifestation of chronic rejection were the episodes of acute cellular rejection or perivascular and interstitial fibrosis, these injuries also being indirect signs mainly detectable at the level of endomyocardial biopsies.

Corresponding author: Ovidiu Simion Cotoi, MD, e-mail:

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24. A rare variant of internal anatomy of a third mandibular molar: a case report

V. Nimigean, Vanda Roxana Nimigean, D. I. Salavastru

The several anatomical variations existing in the root canal system may contribute to failure of the root canal therapy. Knowledge of the internal dental morphology is a complex and extremely important point for planning and performing endodontic therapy. This paper reports the case of a left mandibular third molar that presented only one dental conical root and only one aberrant radicular canal with an initial annular portion situated in the coronar third of the root and a linear portion at the level of the other two thirds of the dental root, which opened through an apical foramen. Root canal therapy and case management are described. Features like wide crown access, adequate illumination and use of exploring files where important for successful completion of the endodontic treatment. The treatment was performed through conventional methods. This clinical case constitutes a rare anatomical variant of internal radicular morphology.

Corresponding author: Victor Nimigean, Professor, PhD, e-mail:

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25. Anatomical variations of the hepatic portal vein associated with incomplete celiac trunk

Dorina Sztika, Delia Elena Zahoi, A. Motoc, Mioara Farca Ureche, Ecaterina Daescu

An association of two anatomical variations was revealed in a 65-year-old male cadaver: the first variation concerns the forming of the trunk of the hepatic portal vein, while the second concerns the branches of the celiac trunk. In this case, the inferior and superior mesenteric veins form a common trunk that is further united with the splenic vein and gives rise to the hepatic portal vein. At the same time, the existence of an incomplete (branched) celiac trunk was revealed, the hepatosplenic trunk from which the common hepatic artery and the splenic artery arise; the left gastric artery arises separately at 0.5 cm superolaterally from the origin of the celiac trunk. Familiarity with this anatomical variation provides useful information for abdominal surgery procedures.

Corresponding author: Delia Elena Zahoi, Professor, MD, PhD, e-mail:

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26. Massive cortico-subcortical ischemic stroke with a consecutive hemorrhagic event: a case report

D. Pirici, Daniela Adriana Ion, L. Mogoanta, Otilia Margaritescu, Ionica Pirici, Camelia Foarfa, Valerica Tudorica, N. M. Panduru, Marieta Coconu, I. A. Checherita

Background: We report a case of a 78-year-old woman with a large cerebral infarction probably due to athermanous embolism following atrial fibrillation. Case description: The patient, known with atrial fibrillation, high blood pressure and heart failure, complained of headache and motor impairment on the left side of the body. CT imaging revealed a subacute ischemic lesion in the right fronto-occipital lobes, and an old ischemic lesion in the right fronto-parietal lobes. Anticoagulant treatment was conducted with careful monitoring of the coagulability status. After almost three weeks, suddenly the patient became comatose and died shortly after. Macroscopic and microscopic examination confirmed the cortico-subcortical ischemic lesions, but also identified a fresh hemorrhagic site in pons, distant from the initial lesion sites. An immunohistochemical study identified blood vessels in the ischemic sites completely isolated from any glial support. Conclusions: This is a rare case of a large cerebral infarction with a pontine hemorrhagic event.

Corresponding author: Daniel Pirici, Teaching Assistant, MD, PhD, e-mail:

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27. Chondrosarcoma of the upper end of the femur

Alina Maria Sisu, F. R. Tatu, Loredana Gabriela Stana, Codruta Ileana Petrescu, Carmen Tatu, A. Motoc

Chondrosarcoma is a malignant tumor that produces cartilage matrix. Occurs in the fourth to sixth decades and has a male to female ratio of 2/1. It is most common in the long bones and on the surface of the pelvis. The authors present a case of chondrosarcoma of the upper end of the femur of a 50-year-old female patient who has come in our Department of Orthopedics and Traumatology two month ago, complaining of severe and persistent pain in the left hip joint and presenting limitation of adduction movement, limitation of internal-external rotation movements, and also could not be able to do thigh flexion on the abdomen. The woman presented a four-month history of persistent and severe pain, not assigned at anti-inflammatory drugs. Laboratory tests not had shown any significance. On radiographies and magnetic nuclear resonance the lesion was shown very clear, deciding for biopsy. The tumor had been large surgical excised with safe limits. Histopathology indicated the histological feature as a differentiated chondrosarcoma, grade III. Our patient has started the chemotherapy and radiation.

Corresponding author: Alina Maria Sisu, Assistant Professor, MD, PhD, e-mail:,

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28. Rhino-cerebral zygomycosis after allogeneic transplant: case report and literature review

Alina Tanase, Zsofia Varady, D. Coriu, Carmen Orban, Camellia Ghita, M. Grasu, A. Streinu Cercel, V. Del Bono

The proportion of patients with hematological malignancies (HM) who develop rare invasive fungal infections (IFI) has increased worldwide over the past few decades. Zygomycosis is an opportunistic fungal infection, which begins in the nose and paranasal sinuses due to inhalation of fungal spores. Rhino-cerebral zygomycosis is the most common form of the disease, it typically develops in diabetic or immunocompromised patients and presents as an acute fulminate infection, which is often lethal. We report a case of rhino-cerebral zygomycosis in an allotransplanted patient to emphasize early diagnosis and treatment of this potentially fatal fungal infection. We discuss different risk factors, specific diagnosis procedures and review the current concepts in management of zygomycosis.

Corresponding author: Alina Daniela Tanase, MD, PhD, e-mail:

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29. The unexpected evolution of a case of diffuse large B-cell non-Hodgkin lymphoma

Amelia Gaman, Adriana Bold, G. Gaman

The diffuse large B-cell lymphoma (DLBCL) represents the most common type of aggressive non-Hodgkin's lymphoma with a heterogeneous morphology, biology and clinical presentation. Gene expression profiling studies identified three distinct molecular subtypes of DLCBL arisen from B-cells at different stages of differentiation: germinal center B-cell-like (GCB) DLBCL, activated B-cell-like (ABC) DLBCL, primary mediastinal B-cell lymphoma (PMBL). The most relevant oncogenic pathways in diffuse large B-cell lymphoma are: deregulated B-cell receptor/proliferation signaling, BCL6 and NF-kB constitutive expression, defects in apoptosis and neoangiogenesis. The treatment of DLBCL has been completely modified in the last ten years by combination of anti-CD20 monoclonal antibody (rituximab) and CHOP chemotherapy, which is now the first line therapy. In the last years, there have been reported several cases of progressive multifocal leukoencephalopathy (PML) at patients with rheumatoid arthritis treated with rituximab. Progressive multifocal leukoencephalopathy is possible as an adverse reaction to rituximab at patients treated with R-CHOP for diffuse large B-cell lymphoma.

Corresponding author: Amelia Gaman, Associate Professor, MD, PhD, e-mail:

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30. A unique case with splitting of the median nerve by the ulnar artery

Arzu Hizay, L. Sarikcioglu

Variations of the median nerve and ulnar artery have been well documented in the literature. In the present case, splitting of the median nerve by the ulnar artery is presented. Our literature searches revealed that there was no article, to our knowledge, describing such splitting. We think that this variation should be kept in mind during surgical and diagnostic procedures.

Corresponding author: Levent Sarikcioglu, Associate Professor, PhD, e-mail:,

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31. Holoprosencephaly sequence

Elena Coleta, Mirela Siminel, Mihaela Gheonea

Holoprosencephaly (HPE) sequence is a rare spectrum of cerebral and facial malformations resulting from incomplete division of the embryonic forebrain into distinct lateral cerebral hemisphere. Three ranges of increasing severity are described: lobar, semi-lobar and alobar HPE. A subtype of HPE called middle inter-hemispheric variant (MIHF) has been also reported. The etiology is heterogeneous: teratogens, chromosomal abnormalities and single gene mutations can be involved. Holoprosencephaly results in early morbidity and mortality with a reduced survival beyond neonatal period. The disorder is estimated to occur in 1/16 000 live births. This case report presents a male new born diagnosed with holoprosencephaly, accompanied by median cleft palate, absent nasal bones and chromosomal abnormalities.

Corresponding author: Elena Coleta, Associate Professor, MD, PhD, e-mail:

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32. Bilateral incomplete discoid lateral meniscus in a 14 weeks fetus: a case report and review of literature

B. V. Murlimanju, Narga Nair, Shakuntala R. Pai, Mamatha Tonse, V. Vinay Kumar

Discoid lateral meniscus is a rare condition that unilateral is more common than bilateral, here we report a case of bilateral discoid lateral meniscus which was observed in the knee joints of a female fetal cadaver of 14 weeks gestation (92 mm crown-rump length). It was an incomplete type of discoid meniscus, occupying about three fourth of the tibial plateau area. The embryological basis of this anomaly is discussed with emphasize on its clinical implications. This finding support the opinion that discoid lateral meniscus as a true congenital malformation that is not found in normal development.

Corresponding author: B. V. Murlimanju, Assistant Professor, MD, e-mail:

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