ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 55 No. 1, January-March 2014

1. Molecular biology of cholesteatoma

Alma Maniu, Oana Harabagiu, Maria Perde Schrepler, Andreea Catana, Bogdan Fanuta, Carmen Aurelia Mogoanta

Cholesteatoma is a non-neoplastic, keratinizing lesion, characterized by the proliferation of epithelium with aberrant micro-architecture into the middle ear and mastoid cavity. The exact pathogenic molecular mechanisms behind the formation and propagation of cholesteatoma remain unclear. Immunohistochemical examinations of the matrix and perimatrix have considerably improved the knowledge of cholesteatoma pathogenesis. In this review, the current concepts of cholesteatoma pathogenesis are discussed. Currently, the most widely acknowledged pathogenesis of acquired cholesteatoma is the theory that negative pressure, dysfunction of the Eustachian tube, causes a deepening retraction pocket that, when obstructed, desquamated keratin cannot be cleared from the recess, and a cholesteatoma results. Local infection leads to a disturbance of self-cleaning mechanisms, with cell debris and keratinocytes accumulate inside the retraction pocket, and this is followed by an immigration of immune cells, i.e., Langerhans' cells, T-cells, macrophages. There is an imbalance and a vicious circle of epithelial proliferation, keratinocyte differentiation and maturation, prolonged apoptosis, and disturbance of self-cleaning mechanisms. The inflammatory stimulus will induce an epithelial proliferation along with expression of lytic enzymes and cytokines. Bacteria inside the retraction pocket produce some antigens, which will activate different cytokines and lytic enzymes. These cytokines lead to activation and maturing of osteoclasts with the consequence of degradation of extracellular bone matrix and hyperproliferation, bone erosion and finally progression of the disease. Further research is necessary for a better understanding of the pathogenetic mechanisms and to expand the spectrum of therapeutic options.

Corresponding author: Alma Maniu, Lecturer, MD, PhD; e-mail: almacjro@yahoo.com

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2. Evaluation of parameters with potential prognosis impact in patients with primary gastric diffuse large B-cell lymphoma (PG-DLBCL)

Ionela Rotaru, Gabriel Dragos Gaman, Casiana Stanescu, Amelia Maria Gaman

Background: Primary gastric lymphoma is the most common malignancy of the stomach after gastric adenocarcinoma. Most cases are represented by the aggressive histological type (diffuse large B-cell lymphoma). Aim: Identification of factors with potential prognosis impact in the aggressive primary gastric lymphoma and the prognosis profile of the patient with impact on the response to therapy and overall survival. Patients and Methods: The study group is composed of 49 patients diagnosed with primary gastric diffuse large-cell non-Hodgkin's malignant lymphoma at "Fundeni" Hematology Clinic of Bucharest and at the Hematology Clinic of Craiova, Romania, in the period 2005-2010. There were evaluated the following parameters in the attempt to establish correlations between the various studied parameters and the response to treatment, in order to establish the prognosis factors: erythrocyte sedimentation rate (ESR), hemoglobin, serum albumin, serum lactate dehydrogenase (LDH), beta-2 microglobulin, presence of serous infiltration, presence of locoregional adenopathies, bulky tumor, stage of disease, international prognostic index (IPI), quick response to therapy (reduction of >50% in tumor volume after two courses), presence of disease relapses, type of treatment - resection + chemotherapy versus chemotherapy alone, chemotherapy versus chemotherapy + Rituximab. Results: We found the following negative prognosis factors: the presence of disease relapse, the value of beta-2 microglobulin higher than 3 mg/dL, the presence of serous infiltration, IPI 3. Conclusions: Identifying prognostic factors is important for personalized therapy approach to obtain optimal response with minimal adverse reaction.

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

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3. Acute leukemia with erythroid hyperplasia. Our experience on a series of cases with acute myeloid leukemia

Elena-Cristina Selicean, Mariana Patiu, Andrei Cucuianu, Delia Dima, Minodora Dobreanu

Diagnosis of myeloid malignancies with erythroid hyperplasia may sometimes confront hematologists with a mathematical dilemma, if cut-off criteria of blast percentage as proposed by the World Health Organization (WHO) 2008 Classification are applied. Several questions have been raised regarding differentiation of acute erythroid leukemia (AEL) from myelodysplastic syndrome with erythroid hyperplasia and some aspects still remain unclear. This paper discusses the differential diagnosis and presents our own experience in a series of patients with acute myeloid leukemia. Although the diagnostic criteria of AEL have been repeatedly refined, it remains a diagnosis primarily based on morphology and on exclusion criteria. Many of the cases designated before 2001 as AEL, actually fit into other disease categories, most often into myelodysplasia related changes - acute myeloid leukemia.

Corresponding author: Elena-Cristina Selicean, MD; e-mail: cristinaselicean@hotmail.com

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4. Proatherogenic adipocytokines levels in metabolic syndrome

Maria Balasoiu, Andrei Theodor Balasoiu, Alex Emilian Stepan, Sorin Nicolae Dinescu, Carmen Silvia Avramescu, Daniela Dumitrescu, Daniela Cernea, Dragos Alexandru

Introduction: Metabolic syndrome was defined by IDF (International Federation for Diabetes, 2007) by abdominal obesity plus at least two of the following: high triglycerides, low HDL-cholesterol, hypertension, high levels of glucose or type II diabetes diagnosed. Obesity is associated with a high cardiovascular risk, abdominal obesity being the most aggressive form, because it secretes cytokines and hormones in comparison to subcutaneous adipose tissue. Adipocytokines secreted by adipose tissue are mediators of atherosclerosis and endothelial damage. Materials and Methods: We studied a total of 80 subjects aged between 40 and 60 years with metabolic syndrome, in which the following adipocytokines values were determined: hs-CRP (turbidimetric method), IL-6, TNF-alpha, leptin (ELISA method), in comparison to a control group. Results: The values of these adipocytokines were significantly higher in the studied group compared with the control group and correlated with increased levels of glucose (patients with type II diabetes or increased tolerance test) and with hyper-triglyceridemia. Conclusions: Patients with metabolic syndrome had increased levels of proatherogenic adipocytokines, particularly leptin, leptin-resistance representing the pathogenic link of obesity. The identification as early as possible of the metabolic syndrome patients allows effective monitoring and correction of cardiovascular risk factors, with the opportunity to reduce morbidity and mortality in young ages. In men, proatherogenic cytokines values presented higher values than in women, which prove the role of abdominal obesity in proatherogenic cytokines production. Although women have a higher percentage of adipose tissue, this is not primarily abdominal adipose tissue.

Corresponding author: Maria Balasoiu, Associate Professor, MD, PhD; e-mail: balasoiu.maria@yahoo.com

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5. VEGF, CD105 and alpha-SMA immunoexpression study in lips squamous cell carcinomas and associated dysplastic lesions

Iulia Roxana Marinescu, Cristiana Eugenia Simionescu, Alex Emilian Stepan, Claudiu Margaritescu, Daniela Cernea, Corneliu Cristian Georgescu, Maria Balasoiu, Daniel Alin Olimid

This study analyzes the microvascular density (MVD) for CD105+ and alpha-SMA+ vessels and VEGF immunoexpression for 35 oral squamous cell carcinomas and for the associated dysplastic lesions of the lips. CD105+ MVD was superior in the advancing edge compared to the intratumoral area, no matter the analyzed clinico-pathological parameters (gender, age, differentiation degree, tumor stage) (p<0.05), MVD being significantly higher in poorly differentiated carcinomas (p<0.05). alpha-SMA+ MVD was also superior in the advancing edge compared to the intratumoral area (p<0.05), MVD values being significantly higher in well and moderately differentiated carcinomas (p<0.05). CD105+ MVD and alpha-SMA+ MVD were significantly lower compared to the analyzed tumor area (p<0.05), in the dysplastic lesions. VEGF score showed significantly higher values in well to moderately differentiated carcinoma and in the tumor area versus dysplastic associated lesions (p<0.05). CD105+ MVD and VEGF are markers able to characterize the angiogenic phenotype of carcinomas and of the dysplastic lesions of the lips, while alpha-SMA+ MVD quantification is useful in assessing the vascular maturity degree.

Corresponding author: Cristiana Eugenia Simionescu, Professor, MD, PhD; e-mail: csimionescu2004@yahoo.com

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6. Immunohistochemical study of Ki67, CD34 and p53 expression in human tooth buds

Monica-Cristina Muica Nagy-Bota, Zsuzsanna Pap, Lorand Denes, Alexandru Ghizdavat, Klara Brinzaniuc, Adina-Simona Lup Cosarca, Manuela Chibelean Cires-Marginean, Mariana Pacurar, Zoltan Pavai

Aim of the study: Establishment of Ki67, p53 and CD34 expression in human tooth buds of different stages of odontogenetic development. Materials and Methods: Tissue samples containing tooth buds were removed from the incisor areas of human fetuses in different stages of development (weeks 9-10, 12-13, 13-16, 21-24), and from the canine and molar areas of 21-24 weeks fetuses. The tissue fragments were fixed using formalin and were processed using common histological techniques with paraffin embedding. Immunostaining for Ki67, p53 and CD34 has been performed using the dextran method and moist heat antigen retrieval (except for CD34). The resulting slides were photographed and quantitatively evaluated. Results: Ki67 immunoexpression decreases with advancement of the developmental stage of the tooth bud: in the inner enamel epithelium, between weeks 9 and 16 (IEE), in the preameloblasts (PB) between weeks 13 and 16, in the ameloblasts (AB) between weeks 21 and 24; outer enamel epithelium (OEE); stratum intermedium (SI); in the dental papilla: between weeks 9 and 10 in the dental papilla (DP), between weeks 13 and 16 in the outer layer of the dental papilla (DP1) and in the central layer of the dental papilla (DP2). Likewise, we noted Ki67 expression in the odontoblast layer (O) and pulp (P), between weeks 21 and 24. Concerning CD34 expression, we observed a decrease from weeks 9-10 until weeks 13-16, followed by an increase until weeks 21-24 of intrauterine life. From weeks 9-10, we observed a constant decrease of expression until weeks 13-16, followed by an increase during weeks 21-24. Conclusions: All Ki67, p53 and CD34 have been identified in the tooth bud. Ki67 expression gradually decreases with the embryonic development of the tooth, while p53 and CD34 expression decreases from weeks 9-10 to weeks 13-16 of intrauterine life, followed by an increase until weeks 21-24.

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

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7. Diagnostic value of HBME-1, CD56, Galectin-3 and Cytokeratin-19 in papillary thyroid carcinomas and thyroid tumors of uncertain malignant potential

Adela Nechifor-Boila, Ramona Catana, Andrada Loghin, Tatiana Georgiana Radu, Angela Borda

Aim: We aimed to evaluate four immunohistochemical markers (HBME-1, Galectin-3, Cytokeratin-19 and CD56) used alone or in panels in a series of papillary thyroid carcinoma (PTC) and thyroid tumors of uncertain malignant potential (TT-UMP) cases. Materials and Methods: We performed an immunohistochemical analysis on a tissue micro-array of 11 PTCs [six classic (CPTC), five follicular variant (FVPTC)] and 31 TTs-UMP. A control group of 11 benign thyroid lesions/tumors was also included. Results: CD56, whose expression is reduced or absent in thyroid carcinomas, was the most sensitive marker (81.8%), showing a "malignant" profile in 5/6 CPTCs and 4/5 FVPTCs. It was followed by HBME-1 (63.6% sensitivity). Cytokeratin-19 and Galectin-3 were the least sensitive antibodies (45.6%), but the most specific ones (100%). Three panels consisting of CD56 and/or Cytokeratin-19/Galectin-3 and HBME-1 and/or CD56 reached the highest sensitivity (90.9%) and the highest negative predicting value (87.5 and 83.3, respectively). In TTs-UMP, Cytokeratin-19, Galectin-3, HBME-1 and CD56 stained negatively in most of the cases (90.3%, 83.9%, 87.1% and 61%, respectively) and no statistically significant differences compared to the benign thyroid lesions' immunoprofile could be observed. Conclusions: New panels of antibodies, consisting of CD56 and/or Cytokeratin-19/Galectin-3 and CD56 and/or HBME-1 that were found to be highly sensitive for PTC in our study, are reported. Applying these panels to TTs-UMP seems also useful. Our results showed that these tumors have an immunoprofile similar to the benign thyroid lesions, suggesting that they are most likely to have a benign rather than a malignant biological behavior.

Corresponding author: Andrada Loghin, Lecturer, MD, PhD; e-mail: andradaloghin@yahoo.com

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8. Determination of autophagy gene ATG16L1 polymorphism in human colorectal cancer

Elena-Raluca Nicoli, Theodor Dumitrescu, Constantin-Daniel Uscatu, Florin-Dan Popescu, Ioana Streata, Simona Serban Sosoi, Petar Ivanov, Alexandra Dumitrescu, Alexandru Barbalan, Dan Lungulescu, Florin Petrescu, Michael Schenker, Doina Verdes, Adrian Saftoiu

Autophagy has emerged not only as an essential repair mechanism to degrade damaged organelles and proteins but also as a major player in protection of tumor cells from multiple stresses. It was shown that autophagy gene polymorphisms are correlated with development of chronic inflammatory lesions, which represent a risk factor for colorectal tumors. In this study, we aimed to determine if ATG16L1 +898A>G (Thr300Ala) polymorphism is associated with an increased risk of developing colorectal cancer (CRC) and to establish correlations between ATG16L1 genotypes and the major clinical and morphological parameters. We observed that subjects carrying GG genotype were at a higher risk for CRC (OR 1.99, 95% CI: 1.02-3.91, p=0.039) when compared with the more frequent AA genotype, furthermore this was even more consistent in male subjects (OR 2.72, 95% CI: 1.11-6.63, p=0.019) but not in female subjects (OR 1.29, 95% CI: 0.43-3.86, p=0.652). In addition, we noticed a correlation between ATG16L1 GG genotype and tumor stage in moderately and poorly differentiated CRC cases. GG genotype carrying patients were at a higher risk for CRC (OR 5.19, 95% CI: 1.50-17.87, p=0.002) when compared with the more frequent AA genotype. Such correlation suggests a possible role of autophagy gene polymorphisms in the development of human colorectal cancer.

Corresponding author: Elena-Raluca Nicoli, RPh, PhD student; e-mail: raluca@nicoli.ro, ralucanicoli@gmail.com, raluca.nicoli@pharm.ox.ac.uk

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9. Cultivation and characterization of limbal epithelial stem cells in rabbits

Ovidiu Samoila, Olga Soritau, Lacramioara Totu, Sergiu Susman, Carmen Mihaela Mihu

Purpose: In the last decades, strong evidence emerged regarding the presence of stem cells located at the corneal limbus. Our objective was to find a way to isolate and cultivate rabbit corneal stem cells in vitro, into an epithelial tissue. Materials and Methods: Two in vitro systems were developed to culture rabbit corneal stem cells: (1) limbal biopsies used as explants and cultivated on fresh denuded amniotic membrane and (2) a monolayer culture obtained by enzymatic treatment of the corneal biopsies. Genetic characterization (PCR) was performed. Specific triggers were used to induce differentiation of corneal stem cells. Results: At four weeks, 16 explant samples out of 18 cultures showed good expansion, ranging from 1 cm to 2 cm. Genetic characterization showed similar expression of genetic stem markers for corneal stem cells and placental stem cells, previously characterized (stem cell factor, Oct3/4, Vimentin, Nestin and Neurofilament). Corneal stem cells showed high Rhodamine efflux and were effective progenitors for neuronal, myocardial, osteogenic and endothelial lineage. Conclusions: In one month, it was possible to grow enough epithelial tissue with preserved proliferative state to allow transplantation on the cornea.

Corresponding author: Ovidiu Samoila, MD; e-mail: iovidius@yahoo.com

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10. Early onset of podocytes apoptosis - a TEM study in streptozotocin-induced diabetic rats

Elena Balasescu, Mugurel Constantin Rusu, Alexandra Diana Vrapciu, Nicolae Mirancea, Vasile Sorin Manoiu, Cristinel Ionel Stan

Cell death types are usually defined by morphological criteria. Even though podocyte loss is associated with various cell death mechanisms, podocyte apoptosis is rarely detected. The purpose of this study is to evaluate whether morphological signs of apoptotic cell death could be detected in early streptozotocin-induced diabetes in rats kidneys. There were used five Wistar rats, and renal tissue samples were drawn after three weeks of disease and further evaluated in transmission electron microscopy (TEM). Podocytes damage was indicated by two major findings: foot processes effacement, viewed as loss of cell processes, and chromatin condensation and margination (partial karyopyknosis: peculiar nuclear morphologies - partly normal, euchromatic, and partly positive for karyopyknosis and nuclear shrinkage). Mitotic glomerular endotheliocytes were also encountered. Podocytes cell death commitment and detachment appeared as concomitant events. However, karyopyknosis is not a specific feature of apoptosis. Thus, further biochemical evaluations are needed to distinguish between different pathways of podocytes death.

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

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11. Morphologic evaluation of the renal veins: a study with autopsy material from Colombian subjects

Luis Ernesto Ballesteros, Vladimir Saldarriaga, Luis Miguel Ramirez

Renal venous drainage presents a large degree of variability. The purpose of this study was to determine the morphological expression of the renal veins. Renal vein formation patterns, their morphometry, and frequency of additional veins were studied in a sample of 156 pairs of kidneys, the vascular beds of which were subjected to an injection-corrosion technique, taken from cadaver specimens autopsied at National Institute of Legal Medicine and Forensics Sciences in Bucaramanga, Colombia. A single renal vein (RV) was found bilaterally in 122 (78.2%) samples, whereas 34 (21.8%) kidneys had additional RVs (left side 33 cases, right side one case). Of the specimens with multiple right renal veins (RRV), 28 (17.9%) had two RVs and five (3.2%) had three RVs. Of the left kidneys, 99.4% had one LRV and 0.6% had two LRVs. The lengths of the left and right renal veins were 56.5+/-12.7 mm and 23.6+/-8.21 mm, respectively; the caliber of the left renal vein (LRV) was 12.3+/-1.41 mm, whereas the caliber of the RRV was 10.9+/-1.56 mm, a statistically non-significant difference (p=0.262). 82.7% of the LRVs and the 73.1% of the RRVs (p=0.768) originated at the extra-hilum level. Renal vein formation pattern characterized by the confluence of upper and lower tributaries was found in 61.6% of the cases, whereas 16.3% of the specimens had upper, medium, and lower tributaries. Variation patterns found in this study point towards a wide morphological expression of these vessels that needs to be taken into account for both imaging and surgical procedures.

Corresponding author: Luis Ernesto Ballesteros, Professor, MD, MSc; e-mail: lballest56@yahoo.es

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12. Peptidyl-prolyl isomerase Pin1-mediated abrogation of APC-beta-catenin interaction in squamous cell carcinoma of cervix

Poonam Jawanjal, Sudha Salhan, Indrani Dhawan, Richa Tripathi, Gayatri Rath

Objective: The present study was aimed to investigate the importance of Pin1 expression in Squamous Cell Carcinoma (SCC) of cervix and to assess its level with beta-catenin and APC to understand the possible involvement of Pin1 in the regulation of these proteins and subsequent activation of Wnt/beta-catenin signaling. Materials and Methods: Expression of Pin1, beta-catenin and APC was examined in 153 SCC patients by immunohistochemistry and revalidated by western blotting. Results: Of the 153 SCC analyzed, Pin1 was overexpressed in 73 (47.71%) cases. Loss of membranous beta-catenin was noticed in 117 (76.47%) SCCs, whereas 66/153 (43.13%) and 93/153 (60.78%) cases showed its distinct cytoplasmic as well as nuclear accumulation respectively. Down regulation/loss of APC was observed in 69 (45.09%) cases, suggesting the activation of Wnt/beta-catenin pathway in SCCs. Pin1 showed the significant association with nuclear beta-catenin (r=.349, p<0.0001) and cytoplasmic loss of APC (r=-.287, p<0.0001). Both Pin1 as well as nuclear beta-catenin were found to be associated with tumor stage (p=0.004, p=0.031) and tumor size (p=0.022, p=0.003). The Pin1 overexpression showed the significant association with disease free survival (p=0.002) but not with overall survival (p=0.421) of SCC patients. Conclusion: Current results explore the expressional relationship between Pin1, beta-catenin and APC suggesting that Pin1 regulates the activation of Wnt/beta-catenin pathway in SCCs via modulating the interaction between beta-catenin and APC. Furthermore, the significant association of Pin1 and beta-catenin with tumor variables underscores the clinical utility of these proteins in cervical cancer.

Corresponding author: Gayatri Rath, MS; e-mail: gayatrirathvmmc@gmail.com, poonamrnirmal@gmail.com

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13. Cystic fibrosis liver disease - from diagnosis to risk factors

Ioana Mihaiela Ciuca, Liviu Pop, Liviu Tamas, Sorina Taban

Cystic fibrosis (CF) is the most frequent monogenic genetic disease, autosomal recessive transmitted, characterized by an impressive clinical polymorphism and appreciative fatal prospective. Liver disease is the second non-pulmonary cause of death in cystic fibrosis, which, with increasing life expectancy, became an important management problem. Predisposing factors like male gender, pancreatic insufficiency, meconium ileus and severe mutation are incriminated to influence the occurrence of cystic fibrosis associated liver disease (CFLD). Our study included 174 patients with CF, monitored in the National Cystic Fibrosis Centre, Timisoara, Romania. They were routinely followed-up by clinical assessment, liver biochemical tests, ultrasound examinations and other methods like transient elastography, biopsy, in selected cases. Sixty-six patients, with median age at diagnosis 4.33 years, diagnosed with CFLD, without significant gender gap. CFLD was frequent in patients aged over eight years, with meconium ileus history, carriers of severe mutations (p=0.002). Pancreatic insufficiency, although present in 75% of patients with CFLD was not confirmed as risk factor, not male gender, in our study. CF children older than eight years, carriers of a severe genotype, with a positive history of meconium ileus, were more likely predisposed to CFLD.

Corresponding author: Ioana Mihaiela Ciuca, University Assistant, MD, PhD; e-mail: iioanapopa@yahoo.com

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14. Lymph node status assessed through the log odds ratio - a better tool in the prognosis of colorectal cancer relapse

Silviu-Tiberiu Makkai-Popa, Sorinel Lunca, Eugen Tarcoveanu, Eugen Carasevici, Gabriel Dimofte

The current literature related to colorectal cancer shows there is a great inhomogeneity in patient outcome, even between patients in the same stage, which means that the TNM staging does not seem enough anymore to make a therapeutic decision. This is why many of the recent studies focus on the study of prognostic and predictive factors that would make the therapeutic decision-making process more accurate. In the current study, we focused on the study of two lymph node based scores - the lymph node ratio and the log odds ratio and the morphological characteristics of the tumor to try to see if any of them can predict a more aggressive tumor behavior in order to approach the patient in an appropriate way. The study included 25 patients presenting over a period of two years (2009-2011) for a local relapse or a metastasis after curative surgery for colorectal cancer. From the morphological characteristics of the tumor, only the protruding character of the tumor positively correlated at a statistically significant level with the recurrence-free time. We also proved that between the two lymph node scores and the pN stage, the log odds ratio was the one that best correlated with both the number of invaded lymph nodes and the number of resected nodes. The log odds ratio also proved to correlate well with the risk of developing a distant metastasis. Our study also shows for the first time that the log odds ratio is able to stratify patients according to their risk of a fast relapse.

Corresponding author: Sorinel Lunca, Assistant Professor, MD; e-mail: sdlunca@yahoo.com

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15. Colorectal cancer - clinical and morphological aspects

Stelian Stefanita Mogoanta, Ion Vasile, Bogdan Totolici, Carmen Neamtu, Liliana Streba, Cristina Jana Busuioc, Garofita Olivia Mateescu

Introduction: Colorectal cancer (CRC) is one of the most common and most serious malignancies worldwide. Its incidence has increased by more than 200 000 in 2008, both in men and in women. Although CRC is a well-studied malignancy which has a slow progression, known risk factors and pre-neoplastic lesions that can be detected and treated, its incidence is on the rise. In our study, we clinically, histologically and immunohistochemically evaluated a group of 317 patients with colorectal cancer who underwent surgery. Patients and Methods: The trial included 317 colorectal cancer patients hospitalized in the second Department of General Surgery within the Emergency County Hospital of Craiova, Romania, between January 2005 and December 2009, aged between 18 and 89 years. After undergoing clinical and laboratory work-up, all patients were submitted to surgery with curative intent. Resection specimens were collected and histological slides were produced from the biological material. Usual histological staining, Hematoxylin-Eosin and trichromic Goldner-Szekely, as well as immunohistochemistry with anti-Ki67, anti-caspase 3, anti-p53 and anti E-cadherin antibodies was also performed. Results: Regarding gender distribution of cases in the study group was a slightly higher incidence in the number of women affected by neoplasia (n=166, 52.35%) than males (n=151, 47.65%). Analysis of incidence per decade of age showed highest figures between 61-70 years, but we also observed comparable values for the decade 51-60 years. Analysis of topography showed higher incidence of cancer of the rectum (119 cases, representing 37.53%) compared to individual segments of the colon. Average size determined for all locations was 5.05 cm, with a median located at 4.82 and a standard deviation of 1.99. Regarding the degree of cell differentiation, out of the total of 245 adenocarcinomas, a number of 87 (35.52%) were well-differentiated adenocarcinomas, 127 (51.83%) were moderately differentiated, and 31 (12.65%) cases were poorly differentiated adenocarcinomas. Index of cell proliferation, Ki67, had a moderate and intense reaction to all the cases studied. Very few tumor cells were immunohistochemically positive for caspase 3, regardless of the degree of tumor differentiation. E-cadherin was intense in well-differentiated adenocarcinomas. In our study, of 42 colon adenocarcinomas, 29 (69%) were highly positive to anti-p53 antibody, the remaining being negative. Conclusions: Colorectal cancer was diagnosed especially in people over 50 years. Analysis of topography showed higher incidence of cancer of the rectum compared to segments of the colon. More than half were presented in stages III and IV. The histopathological study showed that about 98% of colorectal neoplasms were adenocarcinomas, frequently with moderate differentiation.

Corresponding author: Cristina Jana Busuioc, Assistant Professor, MD, PhD; e-mail: dr_cristinab@yahoo.com

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16. The cytotoxicity of dental alloys studied on cell culture

Laura-Cristina Rusu, Cristina Maria Bortun, Gabriela Tanasie, Angela Codruta Podariu, Flavia Baderca, Caius Solovan, Lavinia Ardelean

The metal alloys used in dental practice are the subject of numerous discussions referring to the effect they have on oral cavity tissues. Numerous scientists established that the organic molecules did not exert a significant influence on the degradation of metallic implants. The aim of this study was to test the cytotoxic potential of the most used dental alloys, the Ni-Cr alloy and the Co-Cr alloy. The tests were made on cell culture of pure cell line dermal fibroblasts and of those obtained from skin biopsies, for both, dental alloys and their eluates. The results were compared with control samples. At seven days after inoculation, we observed the relative similarity between the Ni-Cr alloy and the Co-Cr alloy, where the cells did not detach from the plate and they grow to the edge of the material. In case of the eluates, there were no fragments detached, the cells having a relatively high confluence. Therefore, the cytotoxic effects of the two alloys are similar, even if there are speculations in the literature according to which Ni-Cr alloys would have a more pronounced effect. In conclusion, our study revealed non-cytotoxicity of these two dental alloys, and we believe so they can be used successfully in dental practice.

Corresponding author: Flavia Baderca, Lecturer, MD, PhD; e-mail: flaviabaderca@yahoo.com

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17. Expression of E-cadherin and matrix metalloproteinase-9 in oral squamous cell carcinoma and histologically negative surgical margins and association with clinicopathological parameters

Nooshin Mohtasham, Kazem Anvari, Bahram Memar, Nasrollah Saghravanian, Narges Ghazi, Ali Bagherpour, Mahshid Ramtin

Minimal residual cancer cells may not be detected in surgical margins of oral squamous cell carcinoma (OSCC) with routine histological examination. Using molecular markers at surgical margins can be helpful. We attempted to evaluate the MMP-9 and E-cadherin expression in OSCC samples and tumor-free surgical margins and association with clinicopathological factors. We examined E-cadherin and MMP-9 expression in 58 OSCCs including 19 grade I, 21 grade II and 18 grade III with histological tumor-free surgical margins by immunohistochemistry. Specimens were also divided in two groups: 19 samples as an early and 39 as an advanced stage. For E-cadherin in OSCCs and surgical margins, significant difference was observed between poor and moderate tumor differentiation. Different stages of OSCC demonstrated significant differences with higher expression in early stage tumors. For surgical margins, 82.1% of advanced and 84.2% of early stage samples demonstrated immunoreactivity. Both OSCC samples and surgical margins demonstrated significant differences for MMP-9 between stages with higher immunoreactivity in advanced stage, whereas there were not differences between different grades in surgical margins. E-cadherin and MMP-9 expression at histologically negative surgical margins shows the significance of these markers for prognostic values in OSCC patients with E-cadherin being the preferred predictor.

Corresponding author: Narges Ghazi, Assistant Professor; e-mail: nargess_ghazi@yahoo.com, ghazin@mums.ac.ir

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18. Polyomavirus BK-associated nephropathy after kidney transplantation: a single-center retrospective analysis

Mihai Harza, Dorina Tacu, George Mitroi, Cristina Bucsa, Mihaela Gherghiceanu, Adrian Preda, Gener Ismail, Ioanel Sinescu

Background: Polyomavirus BK-associated nephropathy is a challenging and increasingly recognized cause of kidney transplant morbidity and graft failure. Reported prevalence can vary significantly between centers, averaging 5%. Patients and Methods: The paper reports the clinical and pathologic findings in five patients with BK virus-induced nephropathy. We performed a retrospective study including adult patients with graft dysfunction admitted to our department between 2010-2013. Clinical and biological data were obtained every month during the follow-up period. The biopsies were performed in case of graft dysfunction. All biopsy specimens were examined in light microscopy, immunofluorescence and electronic microscopy. Results: We studied 44 graft biopsies, and we found typical histological findings of polyoma BK nephropathy in five (11.4%) cases. All patients received immunosuppressive regimen based on calcineurin inhibitors, Mycophenolate Mofetil and Prednisone. Four of them were on Tacrolimus-based protocol and one patient was on Cyclosporine regimen. Age of transplant at diagnosis varied between 2 and 113 months (patient on Cyclosporine). In all cases, the BK virus nephropathy diagnostic was established taking into account histological findings, all patients presenting intranuclear viral inclusions seen on light microscopy and electronic microscopy. During the follow-up period, the renal dysfunction worsened in two of the five patients, one of them evolving towards ESRD, even though we minimized the immunosuppressive treatment and administered intravenous immunoglobulin. Conclusions: The prognostic for BK virus nephropathy patients is reserved. Histological picture of BK virus nephropathy is similar to the one of graft rejection, differential diagnosis being difficult in the absence of viral inclusions evidence.

Corresponding author: Gener Ismail, MD, PhD; e-mail: gener732000@yahoo.com

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19. Analysis of gingival microvessels ultrastructure in the animal model study

Olena J. Kordiyak, Zoryana Z. Masna

Objective: The aim of this study was to investigate ultrastructural changes that occur in gingival microvessels on acidotic model of periodontitis in rats. Materials and Methods: Gingival tissue samples were obtained from 80 mongrel male rats, from which 16 represented the negative control group, 16 the positive control group and the rest of 48 the three study groups with acid-induced periodontitis. Specimens were fixed in 1.5% osmium tetroxide solution and examined (x4000-x6000) in transmission electron microscope JEM-100 CX II (JEOL Ltd., Japan) with an embedded AMT Digital Camera. Results: In study groups, substantially reduced vascular permeability, preserved mitochondrial cristae and enhanced microvesiculation in endothelial cells, condensed basement membranes were observed at the closing stage of experiment that contributed to the significantly lower severity of gingival inflammation on visual examination than in positive controls. Conclusions: Our data suggest that the key role in the recovery of endothelial and perivascular integrity is attributed to the stabilization of vascular cells membranes in rats gingiva as the result of protein and lipid metabolism regulation.

Corresponding author: Olena J. Kordiyak, Assistant Professor, DDS; e-mail: kordiyakolena68@gmail.com

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20. Immunohistochemistry in diagnosis and surgical treatment of femoral bone metastasis

Adrian Badila, Radu Radulescu, Maria Sajin, Silvia Terinte, Ion Japie

Background: When the primary tumor is unknown, the biopsy and the histopathological examination (associated with immunohistochemistry and molecular profiling) will identify the type and subtype of the tumor and, if possible, the site of origin. The classification in type and subtype will allow to assess the prognosis and to indicate the most appropriate therapeutic approach. Aim: Identification of the unknown primary tumor by biopsy and immunohistochemistry from the femoral bone metastasis, the clinical results and the survival rate after osteosynthesis +/- cement stabilization of the lesion. Patients and Methods: 52 patients with femoral metastasis were included in a prospective study. The gender ratio was 30 women/22 men (average age - 64 years and six months; range: 33-82 years). Thirty-three patients had pathologic bone fracture, while 19 had osteolytic lesions without fracture. The mean follow-up for survivors was 34 months (range: 17-56 months). Surgical treatment consisted in hemiarthroplasty, osteosynthesis with DHS (Dynamic Hip Screw), proximal femoral nail, locked centromedullary nail or DCS (Dynamic Condylar Screw) +/- cement. In 19 (36.54%) cases, the primary tumor was not known. In these cases, biopsy and histological examination with immunochemistry were performed. Twenty-three (52.27%) patients underwent chemotherapy. Clinical and radiological check-ups were performed every three months in the first year and every six months after that. Results: Pain was ameliorated in all cases. Deambulation was achieved in 45 out of 52 (86.54%) patients. Survival rate was 76.92% (40/52) at six months and 59.61% (31/52) at 12 months. At the end of the follow-up period, 18 (34.61%) patients were alive, 24 (46.15%) were deceased and 10 (19.23%) were lost to follow-up. After eliminating the patients lost to follow-up, the survival rate was 33.33% (9/27) in the pathologic fracture group and 60% (9/15) in the osteolytic lesion without fracture group. Conclusions: Most of the patients (86%) could be mobilized immediately after surgery. The expected survival rate one year after surgery is around 60%. The goals of osteosynthesis are the same, regardless the location of the lesion and the implant used: pain amelioration, appropriate stability for immediate full weight bearing, durability for patientâ??s life expectancy. All extended osteolytic lesions must be reinforced at the time of the surgical procedure. The presence of a pathologic fracture is a negative prognosis factor for the medium term survival rate.

Corresponding author: Radu Radulescu, MD; e-mail: radu_rdlsc@yahoo.com

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21. Correlation between lymphatic vessel density and microvessel density in cutaneous malignant melanoma

Mihaela Paula Toader, Tatiana Taranu, Stefan Toader, Alice Chirana, Traian Taranu

Background: Malignant melanoma is an aggressive neoplasm, known for its propensity to early metastatic spread, via lymphatic as well as blood vessels. Tumor progression to an aggressive phenotype is associated with angiogenesis. Tumor lymphangiogenesis may represent a marker for assessing the risk of metastasis in the regional lymph nodes. Materials and Methods: We studied the lymphatic vessel density in peritumoral and intratumoral areas compared to overall microvessel density in 12 cases of malignant melanoma of the face. All cases were primary invasive melanomas, with a Clark level of invasion III and IV. Lymphatic vessels were marked with D2-40 murine monoclonal antibody and their density evaluated through hot-spot method by examination on optic microscopy (200x). Overall microvessel density was assessed using the same method, vascular endothelial cells being visualized using CD31 monoclonal antibody. Statistical analysis was made using SPSS 17.0 software package (Pearson correlation test and Student's t-test). Results: The disposition and aspect of the lymphatic vessels were different in peritumoral and intratumoral areas. Thus, in peritumoral areas lymphatics were generally regular, large, dilated vessels whereas intratumoral lymphatic vessels were smaller, with an irregular lumen. Lymphatic vessel density was generally higher in peritumoral areas. Intratumoral lymphatic vessel density was lower, but significantly correlated to overall microvessel density in these areas. Overall microvessels density was increased in thick cutaneous melanoma. Vessels in the peritumoral areas were larger and more numerous compared to those found in normal tissue. In cases with a dense peritumoral inflammatory infiltrate, we found the highest vascular density. Intratumoral angiogenesis was moderate in most cases, with irregular, smaller or collapsed vessels. Conclusions: Evaluation of the lymphatic vessel density may prove to be useful for the prognostic assessment in malignant melanoma, as it may predict the patients with a risk of developing lymph node metastasis.

Corresponding author: Stefan Toader, University Assistant, MD, PhD; e-mail: toaderstefan@gmail.com

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22. Immunohistochemical and electron microscopy aspects of the nerve structures from the dental pulp

Horia Manolea, Nicolae Vasile, Mirela Opri, Adrian Fronie, Mihai Raul Popescu

In this study, we have done an immunohistochemical and an electron microscopy examination of normal and inflamed human dental pulp specimens in order to evaluate the morphological aspects of the nerve structures from the dental pulp. The S100 protein immunohistochemical marking allowed us to observe the trajectory of the pulp nervous structures, which appear as continuous bands of high intensity at radicular level, coronary branch out and some branches cross the odontoblastic layer and penetrate in predentin along the dentinal tubules. It appears that not only the nerve structures are positive S100 protein but also macrophages or dendritic cells. The electron microscopic part presents the ultrastructure details of the nervous structures observed on the samples from normal and inflamed pulp conjunctive tissues. Even in acute pulpitis no ultrastructural changes occur in the nerve fibers, prolonged exposure to noxious factors may lead to changes like nerve sprouting.

Corresponding author: Horia Manolea, Lecturer, MD, PhD; e-mail: manoleahoria@gmail.com

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23. PAI-1 4G/5G and MTHFR C677T polymorphisms increased the accuracy of two prediction scores for the risk of acute lower extremity deep vein thrombosis

Tudor Radu Pop, Stefan Cristian Vesa, Adrian Pavel Trifa, Sorin Crisan, Anca Dana Buzoianu

Aim: This study investigates the accuracy of two scores in predicting the risk of acute lower extremity deep vein thrombosis. Patients and Methods: The study included 170 patients [85 (50%) women and 85 (50%) men] who were diagnosed with acute lower extremity deep vein thrombosis (DVT) with duplex ultrasonography. Median age was 62 (52.75; 72) years. The control group consisted of 166 subjects [96 (57.8%) women and 70 (42.2%) men], without DVT, matched for age (+/- one year) to those in the group with DVT. The patients and controls were selected from those admitted to the internal medicine, cardiology and geriatrics wards within the Municipal Hospital of Cluj-Napoca, Romania, between October 2009 and June 2011. Clinical, demographic and lab data were recorded for each patient. For each patient we calculated the prior risk of DVT using two prediction scores: Caprini and Padua. Results: According to the Padua score only 93 (54.7%) patients with DVT had been at high risk of developing DVT, while 48 (28.9%) of controls were at high risk of developing DVT. When Padua score included PAI-1 4G/5G and MTHFR C677T polymorphisms, the sensitivity increased at 71.7%. Using the Caprini score, we determined that 147 (86.4%) patients with DVT had been at high risk of developing DVT, while 103 (62%) controls were at high risk of developing DVT. A Caprini score higher than 5 was the strongest predictor of acute lower extremity DVT risk. Conclusions: The Caprini prediction score was more sensitive than the Padua score in assessing the high risk of DVT in medical patients. PAI-1 4G/5G and MTHFR C677T polymorphisms increased the sensitivity of Padua score.

Corresponding author: Stefan Cristian Vesa, Assistant lecturer, MD, PhD; e-mail: stefanvesa@gmail.com

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24. Unusual median nerve schwannoma: a case presentation

Andrea Anghel, Irina Tudose, Dana Terzea, Laura Raducu, Ruxandra Diana Sinescu

Peripheral nerve sheath tumors are common soft tissue neoplasms and their characterization is often challenging. Although the surgical pathology defines some typical entities, some degree of controversy regarding the classification of these tumors still exists. Newer imagistic and histopathological techniques are crucial for their accurate diagnosis and grading. We present an unusual case of median nerve schwannoma in a young patient, discussing the clinical, surgical and pathological elements, including immunohistochemistry.

Corresponding author: Ruxandra Diana Sinescu, MD, PhD; e-mail: ruxandrasinescu@gmail.com

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25. Single arterial trunk arising from the aortic arch with aortic coarctation. Report of a case. Embryological considerations

Iuliu Fulga, Costinela Georgescu, Valeriu Ardeleanu

Abnormalities of the aortic arch occur mainly due to an abnormal development of the fourth aortic arch in the first 12 weeks of fetal life. These abnormalities may be asymptomatic for a long period, or can develop clinically when vascular rings surround the trachea and esophagus and cause tracheal and/or esophageal obstruction. We present the case of a full-term newborn baby, male. The pregnancy had no medical surveillance from a family physician or an obstetrical. After five days of age, the infant died due to severe malformations, incompatible with life, respectively due to single arterial trunk and aorta coarctation. In the literature, there have been cited several other cases similar to our case; however, this one remains an extremely rare anomaly. We believe that the abnormality is due to a regression on an abnormal site of the fourth left aortic arch, but due to the very small number of these anomalies reported so far, we cannot say with certainty if there is an embryologic reason for these abnormalities.

Corresponding author: Costinela Georgescu, Assistant Professor, MD, PhD; e-mail: costinelag@gmail.com

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26. Ulcerated necrobiosis lipoidica to a teenager with diabetes mellitus and obesity

Virgil Patrascu, Claudia Giurca, Raluca Niculina Ciurea, Corneliu Cristian Georgescu, Marius Eugen Ciurea

Many skin lesions are associated with diabetes mellitus (DM) type 1 or 2, due to the use of antidiabetics or to metabolic and endocrine disorders caused by this disease. Necrobiosis lipoidica (NL) occurs more frequently in patients with DM. Painful ulcerations may occur on NL areas in about 20-25% of the cases and usually they are related to trauma. We present the case of a teenager, male, 17-year-old, having NL with multiple plaques, some of them spontaneously ulcerated after about 33 months of onset. He is known with type 1 DM from 2.5 years and the NL preceding the diagnosis of diabetes mellitus with about six months, presented erythematous-infiltrative skin plaques, some ulcerated for about three months, interesting both shins. Based on clinical, histopathological and paraclinical examinations, we established the following diagnoses: ulcerated NL, type 1 DM, moderate mixed dyslipidemia, class I obesity; commissural candidiasis, juvenile acne. Under treatment with Pentoxifyllinum, Sulodexidum, Ketotifenum and topical therapy with 0.2% Hyaluronic acid two months later, we have managed to heal two of the three ulcerated plaques and of the third has become superficial. We applied 0.5% Fluocortolonum on non-ulcerated plaques recording an improvement after two weeks of treatment. NL is a skin disease with a predilection for the shins, more frequent in patients with diabetes and is a part of palisading granulomatous dermatitis, which leads to skin atrophy. NL is found in the 0.3-1.2% of diabetic patients and is rare in children with diabetes (0.006%). It is more common in the patients with type 1 DM. The onset is in the third decade in diabetic patients and in the fourth decade in non-diabetics. There is no consensus concerning the treatment of NL, and the results are often modest. Antiplatelet agents, corticosteroids (local and general), immunomodulatory drugs, cyclins, wide synthetic antipaludics, heparin, Thalidomide are used. NL treatment is very difficult, especially in the ulcerated forms. Many of the drugs listed have proven efficacy only in isolated cases. Studies are necessary on large series of patients to determine the optimal therapy of NL.

Corresponding author: Virgil Patrascu, Associate Professor, MD, PhD; e-mail: vm.patrascu@gmail.com

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27. Testicular feminization: complete androgen insensitivity syndrome. Discussions based on a case report

Constantin Gingu, Alexandru Dick, Sorin Patrascoiu, Liliana Domnisor, Mihaela Mihai, Mihai Harza, Ioanel Sinescu

Introduction and Objectives: Testicular feminization is the syndrome when a male, genetically XY, because of various abnormalities of the X chromosome, is resistant to the actions of the androgen hormones, which in turn stops the forming of the male genitalia and gives a female phenotype. The androgen insensitivity syndrome occurs in one out of 20 000 births and can be incomplete (various sexual ambiguities) or complete (the person appears to be a woman). The aim of this paper is to present the diagnosis and treatment of a case of testicular feminization. Patient and Methods: A 22-year-old patient is admitted at Gynecology for primary amenorrhea. The clinical examination shows a female phenotype: the breasts are normally developed, but there is no hair in the groins and axillary areas, the labia are small and hypoplastic, the urinary meatus is normally inserted, and the vulva is unpigmented. The gynecological exam reveals that the hymen is present, the vagina has 1.5 cm in length, while the uterus is absent. At Endocrinology, the levels of gonadotropins were measured and found normal (FSH 3.18 mU/mL, LH 15 mU/mL), the progesterone was 5.79 nmol/L, estradiol was 82.39 pmol/L and the testosterone was 4.27 nmol/L. The karyotype was mapped in order to differentiate the androgen insensitivity syndrome from other genetic abnormalities, like the Klinefelter syndrome (46XXY), Turner syndrome (45XO), mixed gonadal dyssynergia (45XO/46XY) or tetragametic chimerism (46XX/46XY). These tests confirmed the suspected diagnosis - testicular feminization (46XY). The pelvic CT scan revealed the lack of uterus and ovaries, hypoplastic vagina, and intra-abdominal prepsoic testes. The testes were removed in order to avoid the malignant risk. We performed laparoscopic bilateral orchiectomy. Results: Surgically, the patient had a simple evolution, being discharged in the second day postoperatory, and estrogen therapy was started from that moment on. Mentally, the patient kept thinking she was a woman, so the decision of telling her the truth was left to the parents. Conclusions: Testicular feminization is a rare disease that must be diagnosed and treated through close work between gynecologists, endocrinologists, geneticians, urologists, and psychiatrists. Bilateral laparoscopic orchiectomy is the best procedure to remove the intra-abdominal testes, in order to avoid their malignant transformation.

Corresponding author: Constantin Gingu, MD, PhD; e-mail: cgingu@gmail.com

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28. Malignant ameloblastoma in an 8-year-old child with metastasis to the lung: case report with a clinicopathologic analysis

Viorel Ibric Cioranu, Daniel Iorgulescu, Vlad Petrescu Seceleanu, Sorin Ibric Cioranu, Carmen Toma, Adrian Ioan Fronie, Iulian Mihai Fagetan, Vasile Nicolae

Ameloblastomas are rare tumors of odontogenic origin, accounting for 1% of all oral tumors. They are benign, but locally highly aggressive tumors. We report here the unusual case of an 8-year-old patient with multicystic mandibular ameloblastoma, who was submitted to surgery for two relapses in six years and metastasized to the lung two years after initial surgery. The first lesion, diagnosed as follicular ameloblastoma, was treated conservatively with enucleation and curettage. Two years later the tumor relapsed into multicystic granular form. A marginal conservative resection was performed, keeping the basilar contour of the mandible, due to the age of the patient. Three months later, on a routine follow-up examination, a lung metastasis was detected with no signs of tumor in the mandibular bone and the patient was submitted to upper right lobectomy. Three years later a new recurrent tumor was detected in the alveolar process and another marginal resection was performed. Histologically, the tumor showed the follicular growth pattern. After a disease-free period of over five years, the patient was again submitted to surgery for mandibular reconstruction. The mandibular bony defect was filled with iliac bone blocks and four dental implants. He underwent oral rehabilitation with an implant-supported overdenture. With a follow-up period of 22 years since first surgery, the patient is currently free of disease.

Corresponding author: Viorel Ibric Cioranu, Professor, DMD, PhD; e-mail: maxfaxsurg@yahoo.com

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29. Psychotic depression due to giant condyloma Buschke-Lowenstein tumors

Adela Magdalena Ciobanu, Camelia Popa, Madalina Marcu, Constantin Florin Ciobanu

A 63-year-old patient, with no psychiatric history, was admitted in the psychiatric department with depressed mood, loss of interest in activities, apathy, insomnia, attention deficit, irritability, social withdrawal, prejudice and abandon delusions. Cerebral computed tomography (CT) scan was normal but the general physical examination revealed a voluminous tumor in the inguino-pubic-ano-genital area measuring 350/80/40 mm, which appeared 15 years ago and grew gradually leading to local rickety hygiene and also to depression, especially in the last time period when the tumor grew faster. The DSM-IV-TR diagnostic was affective disorder due to general medical condition. Surgical exams concluded it was a giant exophytic tumor and was recommended a pre-operative abdominal CT scan, which did not revealed metastatic spread. The treatment consisted in wide radical excision into the tumor-free resection margins. Anatomopathological exam concluded condyloma acuminatum - Buschke-Lowenstein tumor (BLT), a very rare borderline tumor. In post-operative period, progress of depression was spectacular, with the full mental recovery by decreasing the antidepressant and antipsychotic medication, fact that strengthen the initial diagnostic of depression due to a general medical condition. Conclusions: Patients diagnosed with BLT may develop mental disorders especially with devaluation and low self-esteem, social withdrawal and secondary functional impairment. Due to the malignancy risk in such tumors and also the psychiatric unfavorable recovery prognostic in case of continuous general medical condition, the only effective treatment is tumor resection with surgical, oncological, psychiatric postoperative revaluation.

Corresponding author: Adela Magdalena Ciobanu, Lecturer, MD, PhD; e-mail: adela.ciobanu@gmail.com

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30. Complex assessment in progressive multiple sclerosis: a case report

Marius Cristian Neamtu, Ligia Rusu, Oana Maria Neamtu, Rucsandra Danciulescu Miulescu, Mihnea Ion Marin

The study presents the case of a patient with progressive multiple sclerosis in relapses (PPMS) and proposes a comprehensive neuromuscular and biomechanical evaluation in order to achieve a predictive picture of gait evolution and balance disorders with disease progression. Patient and Methods: The evaluation included: clinical, functional and neuromuscular evaluation by tensiomyography (TMG) and biomechanics (by RSscan platform force). Elements evaluated included the calf muscle groups (tibialis anterior and gastrocnemius) and the following parameters were assessed from neuromuscular point of view: contraction time, sustain time, delay, relax time and displacement amplitude after electrical stimulation. Biomechanically, we assessed the subtalar angle, foot loading in metatarsian area, foot balance and pressure center distribution. Results and Conclusions: From neuromuscular point of view, we concluded that the right anterior tibial muscle developed compensatory muscle fibers resistant to fatigue. TMG analysis can estimate the possibility of developing gait disorders even in the absence of visible clinical manifestations. We also noted an increased muscle tone in the muscles of bilateral twins. Biomechanical evaluation revealed a symmetrical, abnormal gait, explained by the difference in the angle of left and right foot and in subtalar angle, which expresses the degree of coordination and control of foot gait initiation and execution. In this context, there is an exorotation of both feet.

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

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31. Solitary fibrous tumor arising from the mesentery of adult patients. Report of two cases and review of the literature

Jose Fernando Val-Bernal, Marta Mayorga, Fidel Fernandez, Alejandro Parra, Juan Crespo, Manuel Garcia-Polavieja

Solitary fibrous tumors (SFTs) represent an uncommon entity most frequently manifested in the pleura. We describe herein two new cases located in the jejunal and sigmoid mesentery incidentally found in patients aged 61 and 32 years. In a review of the literature, we have compiled 15 mesenteric SFTs including our two cases. The mean age of the patients at presentation was 51.7 years (range, 26-83 years). Most patients were males (males:females 4:1). Although occasionally these tumors were an incidental finding, the majority have been symptomatic. Tumors varied greatly in size (3 to 25 cm), but most of them were large (mean 14.8 cm). Most cases (60%) were located in the small intestine mesentery. The hemangiopericytomatous (cellular) variant was the most common. All patients were treated by surgery and no other therapeutic approaches (chemo-/radiotherapy) were used. Follow-up data were available in 11 cases and ranged from six days to 21 years, with a mean follow-up period of 36.2 months. None recurred or metastasized. Two (13.3%) of the 15 cases showed atypical histological features concordant with histological, but not clinical malignancy. The main differential diagnosis includes gastrointestinal stromal tumor, synovial sarcoma and reactive nodular fibrous pseudotumor of the mesentery. In one third of the cases, tumor excision did not require intestinal resection. To our knowledge, our Case No. 1 is the first reported that has been removed through laparoscopic surgery. Radical surgery remains the treatment of choice. The unpredictable behavior of SFTs requires a careful, close, long-term follow-up.

Corresponding author: Jose Fernando Val-Bernal, MD, PhD; e-mail: apavbj@humv.es

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32. Plurimalformative syndrome associating trisomy 18 and omphalocele. Case report and review of the literature

Elena Tarca, Petru Plamadeala, Bogdan Savu

Trisomy 18 or Edwards syndrome is a rare chromosomal anomaly, associated with mild to severe intellectual disabilities and multiple congenital anomalies. Trisomies 18 and 13 are lethal, only 5-10% of patients surviving the first year of life. Although prenatal biological and ultrasound investigations are mandatory and free and the detection rate of chromosomal abnormalities is high, the birth of children with no real chance at a normal life being thus avoided by therapeutic abortion, the parents of the here presented child did not benefit from medical examination or prenatal tests, unfortunately the case of many families in Romania. The policy of limiting medical intervention in newborns with Edwards syndrome due to the broad spectrum of severe congenital malformations, severe mental retard and reduced life expectancy is unanimously accepted, but yet difficult to apply from an ethical point of view. That is why very important for both healthcare providers and families to have accurate and detailed knowledge of survival, disease course, and quality of life so that they can make fully informed decisions regarding care of these babies. The particularity of this case is the association of multiple congenital anomalies in a male newborn with trisomy 18, almost all apparata and systems being affected, with the presence of an omphalocele and complete right labiopalatine cleft, which are less frequent at children with trisomy 18.

Corresponding author: Elena Tarca, Assistant Professor, MD; e-mail: tulucelena@yahoo.com

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33. One hundred years of tumor suppressor research: crucial achievements and unique perspectives

Razvan T. Radulescu

Tumor suppressors constitute the body's primary defense line against malignant transformation. Since Theodor Boveri's initial insight one century ago, a huge amount of knowledge on these molecules has been generated. However, the final step of application of this profound understanding in the clinical setting, i.e., the treatment of cancer patients with tumor suppressors and their derivatives, is still ahead. Nevertheless, the important success achieved with similar biomimetic approaches in the therapy of other diseases suggests that tumor suppressor-based antineoplastic interventions should be accomplished soon as they may be equally rewarding.

Corresponding author: Razvan Tudor Radulescu, MD, PD Dr. med.; e-mail: ratura@gmx.net

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34. The practical utility of synthetic tumor suppressor peptides: a personal retrospective on 25 years

Razvan T. Radulescu

In this brief survey, I look back upon a quarter of a century of my personal experience with synthetic peptides. Thereby, I focus on major steps in the design and experimental exploration of peptides that I have derived from the retinoblastoma tumor suppressor protein (RB). Along this way, both Merrifield's solid phase peptide synthesis method and collaborations with established investigators in the peptide and cancer research fields have played an important role.

Corresponding author: Razvan Tudor Radulescu, MD, PD Dr. med.; e-mail: ratura@gmx.net

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35. Letter to the Editor. Attitude of students towards plagiarism

Beuy Joob, Viroj Wiwanitkit

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Corresponding author: Beuy Joob, PhD; e-mail: beuyjoob@hotmail.com

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36. Conference Announcement: The XIIth National Symposium on Microscopic Morphology with international participation, May 28-31, 2014, Craiova, Romania

Laurentiu Mogoanta

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

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