ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 53 No. 2, April-June 2012

1. The role of IgG4 in cutaneous pathology

A. Fernandez-Flores

IgG4 is an immunoglobulin subtype that has many physiologic and morphologic peculiarities. In cutaneous pathology, IgG4 has been related to the pathogenesis of many diseases. Moreover, in the recent years, new IgG4-related diseases have been described. Since some involve the skin, either primarily or as part of their systemic manifestations, we have tried to briefly examine some of the cutaneous conditions related to IgG4.

Corresponding author: Angel Fernandez-Flores, MD, PhD; e-mail: gpyauflowerlion@terra.es

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2. The mandate for a proper preservation in histopathological tissues

Maria Comanescu, D. Arsene, Carmen Ardeleanu, G. Bussolati

A sequence of technically reproducible procedures is mandatory to guarantee a proper preservation of tissues and to build up the basis for sound diagnoses. However, while the goal of these procedures was, until recently, to assure only structural (histological and cytological) preservation, an appropriate preservation of antigenic properties and of nucleic acid integrity is now additionally requested, in order to permit pathologists to provide the biological information necessary for the adoption of personalized therapies. The present review analyses the sequence of technical steps open to critical variations. Passages such as dehydration, paraffin embedding, sectioning and staining are relatively well standardized and allow adoption of dedicated (automatic) apparatuses, while other pre-analytical steps, i.e. time and modalities of transfer of surgical specimens from the surgical theatre to the pathology laboratory (s.c. "ischemia time") and the type and length of fixation are not standardized and are a potential cause of discrepancies in diagnostic results. Our group is involved in European-funded projects tackling these problems with the concrete objective of implementing a model of effective tumors investigations by high performance genetic and molecular methodologies. The problem of the discrepant quality level of histopathological and cytological preparations involved five European countries and exploiting the potential of "virtual slide technology". Concrete issues, techniques and pitfalls, as well as proposed guidelines for processing the tissues are shown in this presentation.

Corresponding author: Gianni Bussolati, Professor, MD, PhD; e-mail: gianni.bussolati@unito.it

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3. Morphology and morphopathology of hypopharyngo-esophageal cancer

B. Popescu, C. R. Popescu, Raluca Grigore, Carmen Aurelia Mogoanta, Elena Ionita, C. Moculescu, S. V. G. Bertesteanu

Cervical esophageal cancer and hypopharyngeal cancer represent a major diagnostic issue in early stages, considering the fact that the implication of both cervical esophageal and hypopharyngeal cancers shows a poor prognostic from the very beginning. Positive diagnosis can only be made after histopathological analysis and immunohistochemical analysis in addition. The bioptic material is sampled by rigid endoscopy this being the only viable method of assessing data on the tumor prior to the surgery. As much as 95% of tumors located at this site are epidermoid carcinomas with different staging and characteristics, other types of tumors being adenocarcinomas, lymphomas, etc. Several risk factors influence the biology of this site thus inflicting both cellular and molecular modifications that are the origin of cancer development.

Corresponding author: Serban Vifor Gabriel Bertesteanu, MD, PhD; e-mail: vifor2001@yahoo.com

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4. Natural products locally modulators of the cellular response: therapeutic perspectives in skin burns

G. D. Mogosanu, Florina Carmen Popescu, Cristina Jana Busuioc, H. Parvanescu, I. Lascar

Local cellular response plays a major role in restoring skin integrity, in burns with infectious complications, chronic fibrous sequelae, etc. For the study of wound-healing process, different experimental models of skin burn were developed. Mice, rats, rabbits and guinea pigs are the most used laboratory animals, kept under standard conditions of light, temperature, food and water (ad libitum). Commonly, by intramuscular injection, general anesthesia was induced with ketamine hydrochloride. Most times, skin burns were inflicted on the dorsal region of animals. Metal devices with different shapes and weights, heated in water at various temperatures were applied locally, for few seconds. The paper reports on 65 natural medicinal products recommended for the external and internal treatment of skin damages (first- or second-degree burns, various wounds, ulcerations). Some of them are traditionally used in the Romanian ethnopharmacology, supporting the wound-healing process mainly because of their epithelizing, astringent, emollient, demulcent, anti-inflammatory, antimicrobial, immunomodulatory and antioxidant properties.

Corresponding author: George Dan Mogosanu, Assistant Professor, Pharm, PhD; e-mail: mogosanu@umfcv.ro

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5. Detection of BRAF V600E mutation in thyroid fine-needle aspiration specimens by High Resolution Melting (HRM) analysis

Adela Nechifor-Boila, Myriam Decaussin-Petrucci, Sophie Gazzo, Ionela Pascanu, Angela Borda

Aim: The aim of our study was to test the feasibility of High Resolution Melting (HRM) analysis for detection of BRAF V600E mutation in various types of fine-needle aspiration (FNA) specimens from patients with papillary thyroid carcinoma (PTC). Materials and Methods: We analyzed fresh thyroid aspirates and smears from eight cases of PTC: three classic PTCs (CPTC), three follicular variant of PTCs (FVPTC), one tall cell, and one oncocytic variant of PTC. DNA extraction was performed using a MasterPure purification kit. The isolated DNA quantity was assessed using a NanoDrop spectrophotometer and the DNA quality was tested by PCR amplification of beta-globin gene and by native DNA electrophoresis. HRM was performed on a LightCycler 480 (Roche). We amplified the 15th exon of BRAF gene, using selected primers to flank the BRAF V600E mutation point. Results: For all types of cytological specimens, the quantity of isolated DNA was adequate and allowed amplification. Similarly, the DNA quality control did not show signs of DNA degradation and the DNA was amplifiable for beta-globin gene. Four cases revealed the BRAF V600E mutation: two CPTCs, one oncocytic PTC, one tall cell PTC. None of the three cases of FVPTC had this mutation. Conclusions: HRM analysis represents a feasible and reproducible molecular technique, offering new perspectives for detecting BRAF mutation in various FNA specimens. In our study, BRAF V600E mutation revealed a strong association with specific histological variants of PTC: highly specific for CPTC, tall cell or oncocytic PTC, but negative in all cases of FVPTC.

Corresponding author: Adela Nechifor-Boila, MD; e-mail: adelanechifor@gmail.com

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6. Histological and immunohistochemical changes of the myocardium in dilated cardiomyopathy

R. I. Radu, Adriana Bold, O. T. Pop, D. Gh. Malaescu, Irina Gheorghisor, L. Mogoanta

Dilated cardiomyopathy is a major cause of heart failure and a major cause of morbidity and mortality. It is a multifactorial disease that includes both hereditary and acquired forms. It is estimated that around 20-35% of patients with dilated cardiomyopathy have hereditary forms. It is the third most common cause of heart failure and the most common cause of heart transplant. Dilated cardiomyopathy can be a secondary condition of many diseases such as coronary heart disease, diabetes, pheochromocytoma, infections, malnutrition, ingestion of toxic substances (alcohol, cocaine), ingestion of chemotherapeutic drugs, autoimmune diseases. In our study, we aimed to describe the changes of myocardial cells and interstitial connective tissue in patients clinically diagnosed with alcoholic dilated cardiomyopathy. The material studied consisted of heart fragments sampled from the left ventricle (LV) during necropsy from a total of 28 patients, aged between 58 and 73 years, with a clinical and laboratory diagnosis of dilated cardiomyopathy, hospitalized in the Cardiology Center of the Emergency County Hospital of Craiova in 2009 and 2010. In dilated cardiomyopathy, myocardial muscle fibers appeared slightly elongated or wavy, with hypochromatic, heterogeneous, vacuolar sarcoplasm, by a decrease of myofibril numbers. Lipofuscin granules were frequently seen in the sarcoplasm. Nuclear changes were consistent with sarcoplasmic alterations. Changes of the interstitial connective tissue were sometimes extensive and sometimes barely noticeable. The most common alteration of this structure was the onset and development of a mainly perivascular collagen fibrillogenetic process.

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

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7. Study of molecular prognostic factors Bcl-2 and EGFR in rectal mucinous carcinomas

Georgeta Afrem, S. S. Mogoanta, F. A. Secureanu, A. Olaru, Carmen Neamtu, B. D. Totolici, M. Ionila, Stefania Craitoiu

Colorectal cancer is an important public health problem worldwide, being the fourth most common cancer in men and the third most common in women. Colorectal cancer incidence is higher in developing countries due to the prevalence of obesity associated with reduced physical activity. Rectal mucinous carcinomas, especially the "signet ring cell" type, have a worse prognosis compared with other varieties of colorectal carcinomas, being diagnosed in more advanced stage and more prone to lymph node and peritoneal metastases. Our study comprised 37 cases with rectal adenocarcinoma with mucinous component operated in the Surgical Clinics of the Emergency County Hospital of Craiova, between 2006 and 2010. The aim of this study was to evaluate some molecular prognostic factors for rectal mucinous carcinomas namely B-cell lymphoma 2 (Bcl-2) and epidermal growth factor receptor (EGFR), and their correlations with the main morpho-clinical parameters of these patients. Thus, we immunohistochemically assessed the degree of apoptosis of tumor cells in mucinous rectal carcinomas using the Bcl-2 marker, and tumor aggressiveness using the EGFR responsiveness. In our study, the percentage of Bcl-2+ cases was 43.24%, with no significant statistical correlation between the Bcl-2 expression and histopathological subtype of mucinous adenocarcinoma. The evaluation of tumor aggressiveness in terms of EGFR responsiveness showed a reduced expression in carcinomas correlated with the increase in quantity of the mucinous component. In addition, EGFR reactivity was increased in the tumor invasion front.

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

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8. Morphological variability of the renal artery branching pattern: a brief review and an anatomical study

Ecaterina Daescu, Delia Elena Zahoi, A. Motoc, Aurora Alexa, Flavia Baderca, Alexandra Enache

The segmental branches of the renal artery vary in number and origin. The 1998, Terminologia Anatomica homologates two branches of the renal artery (anterior, posterior) and five segmental arteries: four from the anterior branch and one from the posterior one. The purpose of this study is to evaluate the renal artery branching pattern, the number and origin of the segmental arteries, as well as to review data from similar studies. The study material consisted of 60 formalin-fixed adult kidneys. Dissections and microdissections were performed on the renal arteries and their branches. The branching of the renal artery was prehilar in 81.67% of cases, hilar in 10% and intra-sinusal in 8.33%. The number branches varied as follows: two branches in 42 cases (70%), three branches in 14 cases (23.33%) and four branches in four cases (6.67%). We subsequently analyzed the origin of the segmental arteries and found that in 53% of the cases the segmental arteries arose independently from the renal artery's branches, while in 47% of the cases they derived from common trunks of type I (85%) or II (15%). Type I trunks are those that originate directly from the main renal artery. They divide either into 2-3 segmental branches, or into just 1-2 branches and a smaller trunk (type II). The type II trunks further divide into 2-3 other segmental branches. These common trunks must be taken into account to avoid confusion with the segmental arteries. Knowledge of these variations is useful not only morphologically, but also clinically.

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

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9. Chronic gastritis with intestinal metaplasia: clinico-statistical, histological and immunohistochemical study

Rodica Dirnu, F. A. Secureanu, Carmen Neamtu, B. D. Totolici, O. T. Pop, P. Mitrut, D. Gh. Malaescu, L. Mogoanta

Chronic gastritis has a high incidence in adults, causing progressive destruction of glandular structures, favoring the development of gastric atrophy. The association of chronic gastritis with intestinal type metaplasia of gastric mucosa has a poor outcome as intestinal metaplasia is regarded as a precancerous lesion. Metaplasia is common in patients with Helicobacter pylori infection and also heavy smokers. The aim of our study was to evaluate the relationship between chronic gastritis and intestinal metaplasia. The study was conducted on a total of 1218 patients, aged between 5 and 90 years, who presented for dyspeptic disorders in the period 2007-2010 and were examined clinically and endoscopically. During the gastroscopic examination, fragments of gastric mucosa were collected for the histopathological study and for highlighting the H. pylori infection. For the histopathological study, the Hematoxylin-Eosin and PAS-Alcian Blue stains were performed, while for the immunohistochemical study the anti-TAG72 and anti-PCNA antibodies were used. A diagnosis of gastritis was established in 615 patients, representing approximately 50.5% of all cases. Most cases with gastritis were found in people of middle age. Gastritis was present in almost all age groups, from teenagers to the elders. Of the 615 cases of gastritis, urease test was positive in 353 patients, representing approximately 57.40% of all patients with gastritis. Histopathological examination identified the presence of intestinal metaplasia in 61.60% of patients with chronic gastritis, mostly complete metaplasia. PCNA immunohistochemistry revealed that cell proliferation processes are intensified in intestinal metaplasia. This study highlights the importance of chronic gastritis, intestinal metaplasia, and H. pylori infection in the etiopathogeny of gastric cancer.

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10. Cellular immunophenotypes in human embryonic, fetal and adult heart

Alina Grigore, D. Arsene, Fl. Filipoiu, Florina Cionca, Simona Enache, M. Ceausu, Maria Comanescu, Florica Staniceanu, Carmen Ardeleanu

The cellular immunoprofile of cardiac dysfunctions and lesions of ischemic etiology are insufficiently studied to date, especially regarding the contribution of non-cardiomyocytic structures. Aiming to explore this immunoprofile, we used immunohistochemistry applied on embryonic, fetal and adult normal or ischemic myocardium. We observed a decrease of smooth muscle alpha-actin expression in fetal vs. embryonic cardiomyocytes, its absence in normal adult myocardium and its intense expression in the fibrotic scars of ischemic myocardium. DDR2 and vimentin, which are present in the interstitial cells and cardiomyocytes of the embryo, fetus and normal adult heart, are absent in the fibrotic scar tissue and cicatricial infarction, the latter expressing smooth muscle alpha-actin and CD34. This suggested that myofibroblasts and not local fibroblasts that participate in ischemic remodeling. An EGFR-positive vascular network was better represented in the ischemic heart than in the adult normal one, a fact possibly related to EGFR implication in cardiac ischemic pre- and post-conditioning. Therefore, cardiomyocytes and non-cardiomyocytic cells have an undulating immunoprofile according to the intrauterine life stage or age after birth, and a variable contribution in cardiac lesions, mostly in ischemic ones.

Corresponding author: Carmen Ardeleanu, Professor, MD, PhD; e-mail: cmardeleanu@yahoo.com

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11. Acinic cell carcinoma of the salivary glands: a retrospective clinicopathologic study of 12 cases

Maria Cristina Munteanu, Cl. Margaritescu, Lucia Cionca, N. C. Nitulescu, Luminita Daguci, E. M. Ciuca

Acinic cell carcinoma (ACC) is the third most common epithelial malignancy of the salivary glands in adults, with a low-grade malignancy that mainly occurs in the parotid gland and at a relatively younger age than other salivary gland tumors. We made a retrospective study on our acinic cell carcinoma casuistry aiming their clinico-pathological characterization and comparison with literature data. From 2000 through 2011 in our hospital were diagnosed only 12 cases of ACC. The clinico-epidemiological study revealed prevalence of these tumors in women, in the fourth decade of life and especially occurring in the parotid gland. The most common morphologic pattern of these tumors was a mixture of two or more variants with the solid/lobular and microcystic patterns more frequent associated. In 75% of investigated cases, the pTNM stage was I/II, with no cases of perineural or vascular invasion, but with lymph node dissemination presented in only three cases. Summing all these clinicopathological features, we conclude that for our casuistry the biological behavior of these tumors has been of low-grade malignancy.

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

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12. Effect of prenatal administration of therapeutic doses of topiramate on ossification of ribs and vertebrae in rat fetuses

R. A. Fadel, R. P. Sequeira, M. F. Abu-Hijleh, M. Obeidat, A. H. A. Salem

There are few studies that have addressed the effects of prenatal exposure of topiramate on ossification of the bones derived from the paraxial mesoderm. This study aimed to evaluate skeletal ossification of ribs and vertebrae in 20-day-old rat fetuses after maternal exposure to two therapeutic doses of topiramate. Three groups of Sprague-Dawley pregnant rats were used: control, topiramate 50 mg/kg/day and topiramate 100 mg/kg/day treated groups. Topiramate was administered by gavage from day 6-19 of gestation. Fetuses were collected on day 20 by caesarian section. Fetal bones were stained with alizarin red and ossification was assessed. Results showed significant delayed ossification of ribs and vertebrae in topiramate-exposed fetuses at both doses and the effects were not dose dependent. In all examined groups, there was a direct correlation between the fetal weight and the number of complete ossified vertebral centers. Also, there were significant increases in skeletal abnormalities, particularly in ribs in both treated groups when compared to the control group. In conclusion, therapeutic doses of topiramate should be taken cautiously during pregnancy as they lead to fetal growth restriction and increases abnormalities of axial skeleton in rat fetuses.

Corresponding author: Raouf A. Fadel, MD, PhD; e-mail: raoufre@agu.edu.bh

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13. Histopathological considerations of placenta in pregnancy with diabetes

Lavinia Gheorman, I. E. Plesea, V. Gheorman

The authors present the results of a study on 19 cases of pregnant women with diabetes who delivered in No. 1 Clinic of Obstetrics and Gynecology, Emergency County Hospital of Craiova, between October 1st, 2009 and September 1st, 2011. After delivery, placentas were harvested for the pathology study. The results of this study reveal: villous immaturity, villous edema, presence of basement membrane thickening, congestion of capillaries called "chorangiosis", intra- and extravillous fibrinoid and a deposit of glycogen. The authors state that although these lesions are not pathognomonic for pregnancy with diabetes, they are very suggestive and specific for this association: diabetes-pregnancy.

Corresponding author: Iancu Emil Plesea, Professor, MD, PhD; e-mail: pie1956@yahoo.com

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14. Histopathological and immunohistochemical study of laterocervical lymph node metastases of unknown primary origin

Ramona Denise Malin, Elena Ionita, I. Osman, Carmen Aurelia Mogoanta, Luminita Cioroianu, S. Ciolofan, F. Anghelina, Madalina Enachescu

In this study, we examined histopathologically and immunohistochemically 24 cases of laterocervical lymph node metastases with unknown primary origin. For immunohistochemical study, we used a large panel of antibodies represented by CK7, CK19, CK20, CKAE1/AE3, CK34betaE12, TTF1, HBME-1, CEA, MUC5AC and EBV. In the cases studied tumors accompanied by seemingly primitive adenopathies were located in the thyroid, lung, esophagus, stomach, rhinopharynx, hypopharynx, oropharynx and larynx.

Corresponding author: Ramona Denise Malin, MD; e-mail: ramona_denise@yahoo.com

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15. The diagnostic characteristics of a group of patients with primary gastric lymphoma: macroscopic, histopathological and immunohistochemical aspects

Ionela Rotaru, T. Ciurea, Camelia Foarfa, Alina Daniela Tanase, G. Gaman

Primary gastric lymphoma is defined as the malignant lymphoproliferative disease with initial symptoms located in the stomach, or tumor mass located in the stomach. This paper aims to present the macroscopic, histopathological and immunohistochemical aspects encountered in a group of patients with primary gastric lymphoma, diagnosed between 2005 and 2010 in the Hematology Clinic of Craiova and the Hematology Clinic of "Fundeni" Institute in Bucharest. Materials and Methods: This study was performed on a group of 65 patients diagnosed with primary gastric lymphoma. The positive diagnosis in primary gastric lymphoma is established by the histopathological and immunohistochemical analysis of gastric biopsies, taken during the upper gastrointestinal endoscopy, or of gastric resection samples. We used the monoclonal antibodies CD20, CD10, CD5, k light chain, PCNA (proliferating cell nuclear antigen) and Ki67. Results: The average age of the patients enrolled in the study was 52.55 years. The most common macroscopic feature encountered was the mixed ulcerative-vegetative one. We found two histological types, represented by diffuse large B-cell lymphoma (with or without MALT component), and marginal zone lymphoma (MALT type). Both the MALT type lymphoma and the diffuse large B-cell lymphoma revealed B-cell phenotype. Conclusions: A correct diagnosis is very important in terms of therapeutic approach. The characteristics of the group of patients were: a higher number of the aggressive histological type; an excessive use of gastric resection; none of the cases was a T-lymphoproliferation.

Corresponding author: Ionela Rotaru, Assistant Professor; e-mail: rodirot@yahoo.com

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16. Pathological characteristics and clinical specifications in gastroenteropancreatic neuroendocrine tumors: a study of 68 cases

Elena Stoica-Mustafa, C. Pechianu, Andreea Iorgescu, Monica Hortopan, Simona Olimpia Dima, V. Tomulescu, T. Dumitrascu, C. Ungureanu, D. Andronesi, I. Popescu, V. Herlea

Introduction: Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) represent a group of tumors, having their origin in cells of diffuse endocrine system, with particular clinical course, diagnosis and treatment. Patients and Methods: In our study, were included 68 patients with neuroendocrine digestive tumors admitted, diagnosed and treated in Fundeni Clinical Institute, Bucharest, in the last ten years - 2000-2010 (retrospective study). Results: Thirty-three (49%) patients were males, 35 (51%) females, and the main age was 58.9 years. In 62 (90.3%) cases was possible to find the primary tumor. The examined tumors had different localizations: pancreas - 32 (47.04%) cases (head - 17 (24.99%) cases, and body and tail - 15 (22.05%) cases), stomach - 7 (10.29%) cases, small intestine - 7 (10.29%) cases, 6 (8.82%) cases - unknown primary site (diagnosis was established on metastases), right colon - 6 (8.82%) cases, liver - 6 (8.82%) cases, rectum - 2 (2.94%) cases, and retroperitoneum - 2 (2.94%) cases. Microscopic examination revealed 59 (86.8%) malignant tumors and 9 (13.2%) benign tumors. Using WHO 2000 Classification, 28 cases of malignant tumors were well-differentiated neuroendocrine carcinomas, and 31 cases were poor differentiated neuroendocrine carcinomas. From malignant cases, 25 (42.3%) have distant metastases and 15 (25.9%) lymph node metastases. Conclusions: Cases of gastroenteropancreatic neuroendocrine tumors included in our study had clinical and histopathological features in correspondence with data from literature - slight predominance in women, predominance in 5th and 6th decades of life, the most frequent localizations were at pancreatic level - both head and body and tail, but the rarest were in colon and retroperitoneum. Most of the cases studied, were malignant tumors, from these more than a half were poor differentiated, and a quarter of them having lymph node or distant metastases.

Corresponding author: Vlad Herlea, MD, PhD; e-mail: herlea2002@yahoo.com

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17. A Romanian therapeutic approach to peripheral nerve injury

I. Zegrea, Laura Ioana Chivu, Madalina Georgiana Albu, D. Zamfirescu, R. D. Chivu, Daniela Adriana Ion, I. Lascar

The study of nerve regeneration and functional recovery of the injured peripheral nerves represents a worldwide subject of clinical and scientific research. Our team aimed to obtain the first guide for nerve regeneration, bioartificial and biodegradable, using exclusively Romanian resources and having the advantages of price and quality, over the imported nerve conduits already used in clinical practice. First steps of this project consisted in obtaining the prototype of nerve guide conduit and its' testing in vitro and in vivo. Tests of physicochemical characterization, FTIR (Fourier Transform Infrared) spectrometry, thermal analysis (differential calorimetry, thermo-gravimetry), electron microscopy, water absorption and enzymatic degradation of the obtained prototype were followed by in vivo testing. The first results, obtained on a group of Brown Norway rats who suffered experimental lesions of 1 cm at the level of left sciatic nerve, which have then been repaired using the Romanian conduit prototype, are favorable in terms of biocompatibility, biodegradable capacity and support of nerve regeneration.

Corresponding author: Laura Ioana Chivu, MD; e-mail: chivu_laura@yahoo.com

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18. The importance of immunohistochemical evaluation of the vascular changes from the decidua and placenta in recurrent pregnancy loss

Maria Magdalena Manolea, Olguta Alice Gavrila, Florina Carmen Popescu, Liliana Novac, Garofita Olivia Mateescu

The angiogenesis is a complex process, incompletely understood, regulated by various stimulating and inhibiting angiogenic factors. In the present study, we proposed to evaluate the angiogenic changes that occur in the cases with recurrent pregnancy loss comparing with a control group represented by women with requested abortion. The evaluation of the changes in the vascular bed was made by immunohistochemical methods, evaluating the answer of the curettage products to the mouse anti-human CD31 and CD34 monoclonal antibodies immunolabeling. The endothelial cells reaction to the CD31 antibody was different, very intense in the normal or slightly congestive vessels. The endothelial cells from the strongly congestive vessels had a light and scratchy reaction. We found intense positive reactions in the control group for CD34 in the vessels from the villous axis and also in the vessels from the spongious decidua. In the study group, we found light positive reaction in the vessels from the decidua situated in the proximity of the necrotic areas; we found a light positive reaction also in the vessels and mesenchymal fibroblasts from some chorial villous axis.

Corresponding author: Maria Magdalena Manolea, University Assistant, MD, PhD; e-mail: manoleamaria@gmail.com

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19. Clinical and paraclinical study regarding the macro- and microscopic diagnosis of various anatomo-clinical forms of operated uterine fibromyoma

Diana Vaniova Klimentova, Anca Daniela Braila, Cristiana Simionescu, I. Ilie, M. B. Braila

The research focused on a systematic review of 959 cases operated for uterine fibromyoma (24.8%) from 3859 gynecological surgeries performed over a period of 10 years (2000-2010). Materials and Methods: The important parameters were those related to the general clinical and laboratory data, and especially those focused on the macro- and microscopic histopathological diagnostic methods. Thus, we inserted some details on the methods used for the histopathological examination of surgically removed samples. Results: The age of patients operated for uterine fibromyoma was between 20 and 60 years, with the highest incidence in the 40-50 years group (594 cases - 62.4%). The most frequent anatomo-clinical forms observed were uterine fibromyoma with menometrorrhagia (78.9%), large uterine fibromyoma associated with compression and metrorrhagia (81.1%), uterine fibromyoma with aseptic necrobiosis (33.6%). The other forms showed a reduced frequency. Uterine fibromyoma associated with infertility was found in patients under 40-year-old, their evolution being initially asymptomatic. The incidence of uterine fibromyoma, which degenerated into a leiomyosarcoma, was "0". Discussion: 1/5 of patients operated after the age of 35 years presented with various anatomo-clinical forms of uterine fibromyoma. Several hypotheses are formulated regarding the etiopathogenesis, morphology and embryogenesis of this benign tumor of the myometrium. The estrogen-progestogen hormonal imbalance after this age in correlation with the genetic predisposition lead to the synthesis of various proteins, enzymes, and growth factors, decrease of apoptosis and stimulation of leiomyomatous cells with the development of a large, even gigantic form of fibromyoma, representing the most common form encountered in our study. The medical treatment with progesterone derivatives did not lead to the expected results, radical surgery usually being the final therapeutical approach. Conclusions: Between 31 and 60-year-old, the incidence of operated uterine fibromyoma was 941 cases out of 959 (98.1%). The correlation between the preoperative clinical and laboratory diagnosis, the intra-operative morphological appearance and especially the post-operative histopathological examination was 100%. In all cases of uterine fibromyoma, histopathological examination was and will remain the sovereign exploration for surgical practice in general and for gynecological surgery in particular.

Corresponding author: Diana Vaniova Klimentova, MD; e-mail: licsor_diana@yahoo.com

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20. Angiogenesis in the reparatory mucosa of the mandibular edentulous ridge is driven by endothelial tip cells

Ruxandra Stanescu, Andreea Cristiana Didilescu, Adelina Maria Jianu, M. C. Rusu

Sprouting angiogenesis is led by specialized cell - the endothelial tip cells (ETCs) which can be targeted by pro- or anti-angiogenic therapies. We aimed to perform a qualitative study in order to assess the guidance by tip cells of the endothelial sprouts in the repairing mucosa of the edentulous mandibular crest. Mucosa of the mandibular edentulous ridge was collected from six adult patients, prior to healing abutment placement (second surgery). Slides were prepared and immunostained with antibodies for CD34 and Ki67. The abundant vasculature of the lamina propria was observed on slides and the CD34 antibodies labeled endothelial tip cells in various stages of the endothelial sprouts. Ki67 identified positive endothelial cells, confirming the proliferative status of the microvascular bed. According to the results, the in situ sprouting angiogenesis is driven by tip cells in the oral mucosa of the edentulous ridge and these cells can be targeted by various therapies, as required by the local pathologic or therapeutic conditions.

Corresponding author: Mugurel Constantin Rusu, Senior Lecturer, MD, PhD; e-mail: anatomon@gmail.com

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21. Using the galactomannan antigen assay in the diagnosis of invasive aspergillosis after hematopoietic stem cell transplantation

Alina Daniela Tanase, Anca Colita, Alexandra Marculescu, Cristina Berteanu, A. Streinu Cercel, Maria Stoica, A. Stoica, Daniela Cernea, Sanda Copotoiu, Klara Brinzaniuc, L. Azamfirei

Invasive aspergillosis (IA) is the most common life-threatening infections after hematopoietic stem cell transplant (HSCT). The serum galactomannan (GM) is recognized as an indirect mycological criteria for an early diagnosis of IA. Starting January 2011, we implementing in Fundeni Clinical Institute, Bucharest, for the first time in Romania, the detection of GM antigen (Platelia Aspergillus EIA, Bio-Rad). In 2011, patients undergoing HSCT were screened with the galactomannan ELISA; we performed a retrospective chart review of 162 SCT patients who underwent galactomannan testing. Thirteen of the patients (8.02%) had at least one positive galactomannan ELISA, and four had multiple positive tests. When calculated in reference to a proved or probable diagnosis of aspergillosis, the galactomannan ELISA had a sensitivity of 0.857 and a specificity of 0.913. The positive predictive value was 0.46, and the negative predictive value was 0.993. The Platelia Aspergillus galactomannan antigenemia assay may assist physicians in making an early diagnosis of IA, in correlation with clinical and radiological criteria. The test has a high sensitivity and specificity and a very good negative predictive value. We found the screening of GM ELISA to be a highly specific diagnostic tool in detecting IA manifested in patients undergoing HSCT.

Corresponding author: Alina Daniela Tanase, MD, PhD; e-mail: alinadanielatanase@yahoo.com

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22. Prognosis of colorectal cancer: clinical, pathological and therapeutic correlation

L. Vasile, A. Olaru, M. Munteanu, I. E. Plesea, V. Surlin, C. Tudorascu

Introduction: Significant progress in the knowledge of carcinogenesis and natural history of colorectal carcinoma (CRC), especially in polyp-cancer sequention and time for transition, are important prerequisites for a new approach to diagnosis. Surgical resection is the mainstay therapy for colorectal cancer, and pathologic assessment of the resected specimen provides data for assessment of outcome and rationale for adjuvant therapy. A pathology report includes TNM stage, tumor type, histologic grade, status of resection margins, and vascular invasion. Aim: The purpose of this paper was to highlight the pathological features and their correlations with postoperative evolution and prognosis of this cancer. Patients and Methods: Data was collected using the database system of the Emergency County Hospital of Craiova, Romania. A total of 302 patients from January 2003 to December 2005 were included. Results: The average survival for the entire group was 44.35+/-28.94 months, and the D'Agostino-Pearson test for batch distribution showed abnormal distribution with two peaks, separated by a group of five patients who survived between 37 and 8 months. Fifty-one (38.05%) patients presented a median survival of 73.54+/-10.47 months. Conclusions: Factors that contribute to a favorable prognosis in CRC are vegetant gross tumors and papillary microscopic forms, G1 and G2 degree of differentiation and disease diagnosed in stages I and II.

Corresponding author: Liviu Vasile, Teaching Assistant, MD, PhD candidate; e-mail: vliviu777@yahoo.com

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23. Structural and stereological analysis of elastic fibers in the glans penis of young men

F. Andrade, G. P. Cardoso, Ana Luiza Bastos, W. Costa, M. Chagas, M. Babinski

The extracellular matrix is an important element in penile function and pathology, although little is known about its components in human glans. This study evaluates the morphological organization and volumetric density of elastic fibers in the glans penis of young men without any evidence of urogenital disease at autopsy or medical history. Penile glans were obtained from five young men who died of causes not related to the urogenital tract, ranging in age from 18 to 30 years (mean 24 years). Samples were fixed in formalin, embedded in paraffin, and histologically processed. Tissue was analyzed by light microscopy using Weigert's resorcin-fuchsin, after previous oxidation with oxone. The point-counting method was used for morphometrical evaluation. Quantities were expressed as volumetric densities (Vv) and were determined on 25 random fields for each individual. Elastic system fibers were easily identified. These fibers had tortuous profile and surrounded sinusoids in the glans penis. An irregular elastic fibers network was identified in the mucosa, while in the corpus spongiosum the elastic fibers were longitudinally distributed. Volumetric density of elastic fibers in the glans penis is 29.4%+/-3.1. These data could provide valuable information in order to draw parallels regarding patients with erectile dysfunction. Further studies regarding extracellular matrix of the penis are necessary to better elucidate the relation between elastic fibers and erectile dysfunction.

Corresponding author: Filipe Moreira de Andrade, MD; e-mail: filipeandrade_torax@hotmail.com

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24. Comparative study of neuroprotective effect of tricyclics vs. trazodone on animal model of depressive disorder

Ileana P. Marinescu, Anca Predescu, T. Udristoiu, D. Marinescu

The neurobiological model of depressive disorder may be correlated with the animal model on rat, hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, the increase of cortisol level being specific to the model of depression in women. The neurobiological model of depression in women presents vulnerabilities for some cerebral structures (hippocampus, frontal cortex, cerebral amygdala). A decrease of frontal cortex and hippocampus volumes are recognized in depressive disorder in women, depending on duration of disease and antidepressant therapy. Neurobiological vulnerability may be pronounced through cholinergic blockade. The purpose of the study was to highlight the cytoarchitectural changes in the frontal cortex and hippocampus by comparing two antidepressant substances: amitriptyline with a strong anticholinergic effect and trazodone, without anticholinergic effect. The superior neuroprotective qualities of trazodone for the frontal cortex, hippocampus and dentate gyrus are revealed. The particular neurobiological vulnerability of depression in women requires a differentiated therapeutic approach, avoiding the use of antidepressants with anticholinergic action.

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

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25. The immunohistochemistry aspects in two cases of neurofibromatosis-associated abdominal tumors

Mara Carsote, S. Paun, M. C. Neamtu, Elena Taina Avramescu, Cristina Iosif, Dana Terzea, S. Constantinoiu, Ruxandra Danciulescu Miulescu, Oana Maria Neamtu, Catalina Poiana

Type 1 neurofibromatosis associates various abdominal tumors as gastrointestinal stromal tumors, duodenal or pancreatic carcinoid, and adrenal tumors like pheochromocytoma. We present the immunohistochemistry report in two cases with different profile regarding the evolution. One case is a 7th decade women diagnosed with unilateral pheochromocytoma and GISTs, with a good prognosis after surgery. The other case is a 41-year-old male diagnosed with duodenal metastatic somatostatinoma after an intestinal occlusive syndrome and later the hormonal profile leaded to the diagnosis of pheochromocytoma. The patient had a fulminate evolution within six months from diagnosis.

Corresponding author: Marius Cristian Neamtu, MD; e-mail: drcristianneamtu@yahoo.com

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26. Interdisciplinarity in oro-maxillofacial dysmorphism rehabilitation of a patient with Turner syndrome. A clinical case report

Anca Jivanescu, A. Em. Bratu, Diana Naiche, Adina Scurtu, Cristina Dana Bratu

Statement of the problem: Turner syndrome is a chromosomal disorder that manifests with short stature, gonadal dysfunction, hypothyroidism, congenital heart disease, and distinct craniofacial features including oro-maxillofacial dysmorphism. This paper presents a case of a 30-year-old female patient with Turner syndrome who sought dental care to improve the dental and facial morphology and restore the oral health. Detailed exobuccal examination revealed complex anomalies. Initial periodontal therapy and carious lesions treatment was followed by orthodontic treatment and prosthetic rehabilitation with two porcelain fused to metal fixed partial dental prostheses. Tooth whitening and restoration of the incisal edge of the anterior teeth was performed to complete the smile design improvement. The interdisciplinary approach pursued in this case resulted in successful oral rehabilitation with optimal treatment outcomes and high patient's satisfaction. Clinical significance: Patients with Turner syndrome may present with complex morphologic oro-maxillofacial alterations that require individualized dental treatment plans. Appropriate interdisciplinary medical/dental treatment can lead to successful oral rehabilitation with a minimum of invasive procedures.

Corresponding author: Anca Jivanescu, Assistant Professor, DDS, PhD; e-mail: ajivanescu@yahoo.com

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27. Anatomical variation of mandibular second molar and its implications in endodontic treatment

Ruxandra Margarit, Oana Cella Andrei, Veronica Mercut

The variations of anatomical and morphological characteristics of the teeth are very important for any practitioner. These differences in root morphology are influencing the success of the endodontic therapy and the long-term prognosis of the tooth, especially when it is an abutment for a prosthetic restoration. Before beginning an endodontic treatment, the clinician must take into account the morphological variations of the root anatomy. This article describes the therapeutic approach in a case of mandibular second molar with four canals abnormally located instead of three. This anatomical variation is a major risk for both endodontic and prosthetic treatment failure. The lack of knowledge of root and pulp anatomy permits the errors in diagnosing and treatment planning. Unfilled canals, left like this by omission, can compromise both the endodontic and prosthetic treatment. For the success of the any dental treatment is critical to know the normal configuration of the pulp and to be aware of the possible variations.

Corresponding author: Ruxandra Margarit, Assistant, MD, PhD candidate; e-mail: ruxandra.margarit@gmail.com

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28. Nodal marginal zone lymphoma associated with extensive epithelioid histiocytes

Asmaa Abdou, Nancy Asaad

Nodal marginal zone lymphoma (NMZL) is a rare type of non-Hodgkin lymphoma. In this report, we describe a similar condition affecting female 53-year-old presented with generalized lymphadenopathy and high LDH level. The patient underwent excision of cervical lymph node and bone marrow biopsy. Histopathological examination of the excised lymph node revealed florid infiltrate by epithelioid histiocytes, which greatly underscores the neoplastic process directing the diagnosis towards reactive lesions such as toxoplasmosis, marginal zone hyperplasia or monocytoid B-cell hyperplasia. Careful histopathological examination of interfollicular and parafollicular regions helped in recognition of the pale monomorphic neoplastic cells that showed immunoreactivity for CD20 and Bcl-2 and lacked expression for CD5, CD10 and CD23. The involvement of bone marrow by the same type of cells has excluded the possibility for reactive conditions. The recognition of NMZL is sometimes difficult when benign components predominate such as the presence follicular hyperplasia and epithelioid cell clusters. However, full clinical data including LDH level and asking for bone marrow biopsy were greatly helpful in identifying the correct lesion.

Corresponding author: Asmaa Gaber Abdou, MD, PhD; e-mail: asmaa_elsaidy@yahoo.com, asmaa_abdou27@yahoo.com

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29. Morphological aspects in a urogenital malformation, complex and rare, in a child

Viorica Leordean, D. Lazar, M. Trofenciuc

The aim of this study follows the detailed evolution of a child diagnosed with prune-belly syndrome. This syndrome is a complex dysplasia, a rare pathology in children, characterized by the triad - the classic - hypo- or aplasia of righteous abdominal, cryptorchidism, abnormality of the urinary tract; also, it can be associated with pulmonary, cardiac, digestive, osteoarticular, and other malformations. Diagnostic criteria and etiopathogeny aspects are presented showing embryopathy and X-linked hereditary transmission theories as the most plausible, as proofed by recent genetic studies. Analyzing therapeutic aspects, it is stressed that medical treatment precedes or follows surgery, which cannot resolve urinary infection unless dysplastic urinary reconstruction is performed. Serious forms of prune-belly syndrome have a development and poor prognosis. Intrauterine and neonatal mortality is 20% and 50% in the first two years of life. The risk of urinary infection and/or lungs burdens the patient's clinical condition, allowing further appreciation on evolution of the disease. For cases solvable by plastic surgical reconstruction, as those who respond to medical therapy, differentiation will be monitored in territory and check-ups by the specialized consulting room from Polyclinic Health Center. Urinary infection relapse danger is permanent, requiring differentiated supervision. These case interest practitioners, by at least two aspects: the rarity of the disease, and complexity of dysplasia constituent, which has serious implications on the body economy.

Corresponding author: Viorica Leordean, MD; e-mail: drleordean@gmail.com

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30. Bilateral high origins of testicular arteries: a rare variant

Jing Li, Zhen Feng Ren, Tao Sun

We report a very rare case of bilateral high origins of testicular arteries in a 66-year-old Chinese male cadaver. The arteries originated from the antero-lateral aspect of the abdominal aorta, cranially to the origins of ipsilateral renal arteries. Approximately 1.1 cm after its origin, the right testicular artery gave off the middle suprarenal artery. During its course, the artery crossed anterior to the right renal vessels. The left testicular artery coursed posterior to the left suprarenal vein, anterior to the left renal vessels. Variants of the origin and course of the testicular artery are important during renal and testicular surgeries.

Corresponding author: Jing Li; e-mail: lijing800912@yahoo.com.cn

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31. Iatrogenic inguinal chyle fistula: a rare case report

N. H. Zubaidah, A. Y. Jasmi, H. Hanafiah, A. H. Shaker, C. M. Asri, A. R. Emad, S. Das

Chyle fistula may be common in the neck and thorax region but it is a rare entity in the inguinal region. The rarity of the incidence of chyle fistula and the tremendous response to conservative management are the important aspects to be remembered. We hereby report a case of iatrogenic inguinal chyle fistula complicating a femoral vein cannulation.

Corresponding author: Srijit Das, Associate Professor, MD; e-mail: drsrijit@gmail.com

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32. Ureteral stenosis due to endometriosis

E. T. Trasca, E. Trasca, A. Titu, M. L. Riza, I. Busuioc

Endometriosis is characterized by the presence of endometrial tissue outside the uterine cavity, with potential to undergo malignant transformation. We report the case of a 36-year-old patient with a clinical and imagistic diagnosis of left vaginal pouch and left parametrium tumor. The patient presented lumbar and pelvic pain, dysuria and polakyuria. Ultrasound revealed changes in the left kidney confirmed by the CT scan, which also revealed the presence of a tumor in the left parametrium infiltrating the bladder, juxtavesical ureter, uterus and cervix. Laboratory tests were within normal limits. Surgery consisted of interadnexal hysterectomy, proximal colpectomy, left distal ureterectomy with ureterocystoneostomy. Pathological examination established the final diagnosis of infiltrative deep endometriosis involving the urinary tract. In the case of a young fertile patient with gynecological symptoms and morphofunctional changes of the urinary system, urinary tract endometriosis should always be a diagnostic option.

Corresponding author: Emil Tiberius Trasca, Assistant Professor, MD, PhD; e-mail: etrasca@yahoo.com

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