ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 60 No. 1, January-March 2019

1. State of the art in human adipose stem cells and their role in therapy

Alina Simona Sovrea, Adina Bianca Bosca, Anne-Marie Constantin, Eleonora Dronca, Aranka Ilea

Nowadays, adipose tissue appears to be the most valuable source in regenerative cell therapy, due to the following characteristics: high accessibility, high expression in a large number of individuals, high self-renewal and ability to differentiate, and hematopoietic support to the implant area. Its therapeutic potential has been experimentally observed in a broad spectrum of diseases with high population impact: diabetes, myocardial infarction, Parkinson disease, bone fractures, facial reconstruction or loss of subcutaneous tissue due to congenital abnormalities (e.g., hemifacial microsomy), trauma, burns, and tumors. Over 130 clinical trials using adipose-derived stem cells (ASCs), majority phase I or phase II, have been registered with the National Institutes of Health (NIH), and in the short term no adverse reactions or significant risks were identified. Parallel with regulatory frameworks that control their safety and assess their efficacy, phase III trials are being developed. Although transplantation with adipose tissue is becoming more and more popular, there are still important drawbacks and technical challenges to be addressed, and clinical strategies to be developed. This review explores in a concise manner the present body of knowledge concerning ASCs and their implication in therapy.

Corresponding author: Eleonora Dronca, MD, PhD; e-mail: eleonora.dronca@umfcluj.ro

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2. Unroofed coronary sinus: update on diagnosis and treatment

Eliza-Elena Cinteza, Cristina Filip, Gabriela Duica, Georgiana Nicolae, Alin Marcel Nicolescu, Mihaela Balgradean

Unroofed coronary sinus (UCS) is among the rarest congenital heart malformations in pediatric practice. Often, they are associated with persistent left superior vena cava (PLSVC) draining into the left atrium, and in this situation, there is a double intracardiac shunt, right-to-left and left-to-right. They are asymptomatic in the majority of the cases. Each ordinary imagistic method (transthoracic echocardiography, contrast transesophageal echocardiography, angiography) can be helpful in finding the diagnosis, but enhanced computed tomography scan can give an irrefutable diagnosis. The surgical intervention may consist in the recreation of a roof for the coronary sinus, and anastomosis of the PLSVC to the right atrial appendage.

Corresponding author: Eliza-Elena Cinteza, Lecturer, MD, PhD; e-mail: elizacinteza@yahoo.com

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3. Heterogeneity among diffuse large B-cell lymphoma: new entities in WHO classification, a first step in personalized therapy

Ionela Rotaru, Alina Daniela Tanase, Janina Georgiana Nacea, Stefan Patrascu, Ovidiu Andrei Olteanu, Ana-Maria Patrascu

Diffuse large B-cell lymphoma (DLBCL) is the most common type of aggressive lymphoma, being part of mature B-cell neoplasm according to the 2016 World Health Organization (WHO) Classification of lymphoid tumors. This type of non-Hodgkin s lymphoma (NHL) can develop in the lymph nodes in most cases, or in extranodal sites (the most frequent involvement being the digestive tract, but also the thyroid, central nervous system, testes, etc.). Despite being an aggressive lymphoma, DLBCL benefits of potentially curable therapy. The addition of monoclonal antibodies to standard chemotherapy in the therapeutic approach of DLBCL leads to some net superior results to those obtained by chemotherapy alone. Despite the fact that the aggressive therapy is very efficient, 10% of patients remain refractory to it, 30-40% of them after obtaining a complete response (CR) will relapse, and 90% of refractory DLBCL have poor survival rates. Based on these findings, an explanation for the differences in clinical outcome and therapy response was attempted. The important progresses made in the understanding of DLBCL heterogeneity were based on molecular biology studies and showed differences in chromosomal alterations and in signaling pathways activation. These findings have paved the way for new therapeutic targets in order to improve therapy response. The large heterogeneity of DLBCL is acknowledged by the 2016 WHO Classification of lymphoid neoplasms, with 17 DLBCL subtypes, some of them as new varieties, compared to the 2008 Classification, and others introduced as provisional entities.

Corresponding author: Janina Georgiana Nacea, MD, PhD Student; e-mail: janinanacea@yahoo.com

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4. Complex atrial septal defect closure in children

Hyam Mahmoud, Alin Marcel Nicolescu, Cristina Filip, Georgiana Nicolae, Gabriela Duica, Mihaela Balgradean, Eliza-Elena Cinteza

Atrial septal defect (ASD) is one of the most common congenital heart diseases (CHDs) diagnosed in children. Symptoms in ASD may be absent, but palpitations and dyspnea in children sometimes reveal a complex structural and CHD. Diagnosis is established usually by transthoracic echocardiography, but in more complex cases such as coronary sinus defect, enhanced computed tomography or cardiac magnetic resonance may be used. Indication for closure depends on the dimension and on the hemodynamical impact. There are two methods for closure: surgical and interventional. Surgery may be applied to all types of ASD, while transcatheter closure may be used only for ostium secundum ASD. The most important issue in the interventional closure is the anatomical aspect related to the position of the defect. Both methods may have complications. Complex cases in children usually are not recommended for interventional closure, surgery being the recommended method. Oversizing of the device to be implanted according to the sizing balloon and not to the initial defect diameter may give a solution for large ASDs. Interventional closure of large defects in small children with an aneurysmal, multi-fenestrated, malaligned septum, or with other CHD associated may be challenging. Complications are present for both types of closure, but they are relatively different.

Corresponding author: Eliza-Elena Cinteza, Lecturer, MD, PhD; e-mail: elizacinteza@yahoo.com

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5. The prognostic value of CXCR4, MMP-2 and MMP-9 in tongue squamous carcinoma

Felicia Ileana Ciuca, Petre-Costin Marasescu, Marius Matei, Alma-Maria Florescu, Claudiu Margaritescu, Alin Dragos Demetrian, Irina Dragan, Cristiana Iulia Dumitrescu

Currently, tongue squamous cancer appears to be more frequent, especially among adults under the age of 45. Approximately 50% of these patients are diagnosed late, with clinically detectable metastases; the five-year survival rate of patients with loco-regional metastases is less than 60%. In order to explain this behavior, many investigations have been conducted in recent years, most of them focusing on identification of potential prognostic and therapeutic markers involved in the pathogenesis of tongue cancers. Our research follows the same trend, which aims to study the prognostic implications of immunohistochemical (IHC) expression of markers C-X-C chemokine receptor type 4 (CXCR4), matrix metalloproteinase (MMP)-2 and MMP-9 in 54 cases of tongue squamous carcinoma. The cases were selected from the archives of the Laboratory of Pathology, Emergency County Hospital, Craiova, Romania, from the 2015-2017 period. They were immunohistochemically processed using the labeled Streptavidin-Biotin (LSAB) enzyme detection technique, and as a method of evaluating reactions, the IHC score developed by Remmele et Stegner. Reactivity for the investigated markers was recorded in both primary tumors, parenchymal and stromal, and in lymph node metastases, and also in normal or dysplastic mucosa adjacent to tumor lesions. The maximum tumor reactivity was recorded for CXCR4, followed by MMP-9 and MMP-2. In addition, all of these markers were expressed stronger in the invasion front and especially in the lymph node metastatic forms. This immunoprofile would suggest their implication in loco-regional invasion and dissemination processes, allowing the selection of the most aggressive forms of tongue squamous carcinoma.

Corresponding author: Claudiu Margaritescu, Professor, MD, PhD; e-mail: c_margaritescu2000@yahoo.com; Alin Dragos Demetrian, Lecturer, MD, PhD; e-mail: alin_demetrian@yahoo.com

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6. The role of interleukin-6 as an early predictor of sepsis in a murine sepsis model

Iudita Maria Badea, Razvan Azamfirei, Bianca Liana Grigorescu, Gergo Raduly, Adina Hutanu, Marius Petrisor, Alexandra Elena Lazar, Emoke Almasy, Raluca Stefania Fodor, Adrian Man, Janos Szederjesi, Simona Gurzu, Leonard Azamfirei, Anca Meda Georgescu

Aim: Evaluating the role of interleukin-6 (IL-6) as an early predictor of sepsis in a murine model. Materials and Methods: The study divided 26 Wistar rats into two experimental groups in which sepsis was induced through the intraperitoneal injection of different Escherichia coli cultures [Group 1: Extended-spectrum beta-lactamase (ESBL)-producing culture and Group 2: Standardized ATCC35218 culture] and a control group. IL-6 levels were determined at 5 and 24 hours post-inoculation and immunohistochemistry (IHC) was performed on tissue samples from the sacrificed animals. Results: Mean plasma IL-6 levels in Group 1 peaked at 5 hours [37.4 pg/mL; standard deviation (SD) = 2.4 pg/mL] and decreased at 24 hours (34 pg/mL; SD=3.2 pg/mL) after inoculation. IL-6 levels in Group 1 were elevated compared to Group 2, at 5 hours (33.7 pg/mL; SD=3.3 pg/mL; p=0.019) and non-significantly so at 24 hours (32.5 pg/mL; SD=2.4 pg/mL; p=0.233). The results did not show an increase over control levels at either 5 hours (37.6 pg/mL; SD=3.4 pg/mL) or 24 hours (40.8 pg/mL; SD=2.9 pg/mL) after inoculation. The IHC shows a varying degree of IL-6 expression across all organ types studied. No statistically significant correlations were found between the tissue level quantification of IL-6 and serum values at 24 hours in either group. Conclusions: For an early stage of infection/inflammation, serum levels of IL-6 are not correlated with tissue-level inflammation disproving a potential role of IL-6 as a very precocious diagnostic and predictor test. Accumulation of IL-6 in lung, kidney and spleen tissue can be observed from the beginning of inflammation.

Corresponding author: : Bianca Liana Grigorescu, Lecturer, MD, PhD; e-mail: biancagrigorescu20@yahoo.com; Leonard Azamfirei, Professor, MD, PhD; e-mail: leonard.azamfirei@umftgm.ro

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7. Periocular basal cell carcinoma: demographic, clinical, histological and immunohistochemical evaluation of a series of 39 cases

Claudia Florida Costea, Mihaela Dana Turliuc, Anca Sava, Gabriela Dimitriu, Gabriela Florenta Dumitrescu, Cristina Danca, Andrei Ionut Cucu, Camelia Margareta Bogdanici, Irina Iuliana Costache, Catalin Mihai Buzduga, Manuela Ciocoiu, Daniela Maria Tanase, Raluca Alina Dragomir, Alexandru Carauleanu

Background: Basal cell carcinoma (BCC) is the most frequent malignant epithelial tumor of the periocular area. The clinical and histological classification of periocular basal cell carcinoma (pBCC) is essential in order to establish the risk of recurrence and to compare the results of the treatment. Until now, there is no unitary histological classification of pBCC. Aim: The aim of this study is to identify the demographic, clinical and histopathological characteristics of adult patients with pBCC, in order to obtain useful data for comparison in other investigations and to identify the histological origin of this eyelid tumor, as there are only hypothesis on this issue. Materials and Methods: A descriptive retrospective study was conducted on a series of 39 consecutive patients over the age of 20, who were surgically treated for pBCC in the 2nd Ophthalmology Clinic of the Prof. Dr. Nicolae Oblu Emergency Clinical Hospital from Iasi, Romania, over an 11-year period (July 2007-February 2018). The analyzed data were the following: date of resection, patient age at resection, gender, tumor location, histological subtype, and immunohistochemical (IHC) expression patterns of anti-cytokeratin (CK) antibodies (anti-CK AE1/AE3, anti-CK5/6, anti-CK7, anti-CK17, anti-CK19, anti-CK20) and anti-epithelial membrane antigen (EMA) antibody. Results: A total of 39 histopathologically diagnosed cases of pBCC were evaluated. The mean age at resection was of 66 years (range: 26-87 years). As for gender, 17 (43.6%) were male patients, with a mean age of 64.84 years (range: 26-78 years) and 22 (56.4%) were female patients, with a mean age of 66.68 years (range: 46-87 years). The pBCC occurred on the right side in 18 (46.2%) cases and on the left in 21 (53.8%) cases. Of all removed specimens, 24 (61.53%) involved the lower eyelid, seven (17.94%) the medial canthus, five (12.82%) the upper eyelid, and three (7.62%) lacked the specification of the site. The most common histological subtype was nodular, accounting for 26 (66.7%) cases. Adenoid BCC was identified in four (10.3%) cases, and morpheaform in one (2.6%) case. Squamous differentiation (basosquamous subtype) was identified in eight (20.5%) cases. The IHC profile of pBCC included: strong immunopositivity for CK AE1/AE3, and CK17 all histological subtypes, and CK5/6 positivity only in squamous differentiation areas. No immunopositivity was identified for CK19, CK20, and EMA IHC staining. Conclusions: Our retrospective study indicates that most of pBCCs developed particularly in elderly female patients and tumors were located in the lower eyelid with a left side and lower eyelid preferences. Most of our pBCC cases were histologically classified as nodular subtype, and morpheaform and basosquamous form affected mostly the lower eyelid. pBCC IHC profile showed a strong immunopositivity for CK17, thus suggesting that the origin of this cancer is in the follicular germinative cells. We can conclude that our results showed a demographic, clinical, histological, and IHC profile which seems to be representative for Central and Eastern European countries, maybe due to the same genetic predisposition and environmental factors.

Corresponding author: Mihaela Dana Turliuc, Associate Professor, MD, PhD; e-mail: turliuc_dana@yahoo.com; Anca Sava, Professor, MD, PhD; e-mail: dr.anca.sava.68@gmail.com

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8. Complications related to breast reconstruction after mastectomy using multiple surgical techniques - a national and international comparative analysis

Silviu-Adrian Marinescu, Catalin-Gheorghe Bejinariu, Elena Sapte, Marius Cristian Marinas, Carmen Giuglea

The present paper describes and analyzes complications related to alloplastic breast reconstruction, as well as those associated with surgical techniques involving myocutaneous flaps. The article also contains a comparative analysis of the results obtained with the data in the international specialized literature. The statistical analysis is primary based on data obtained from patients included in the National Breast Reconstruction Program developed within the Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, Romania, between 2015 and 2019. In order to highlight and present a thorough comparison between the possible long-term complications associated with multiple reconstructive techniques, the paper also includes data related to patients who have undergone such surgical interventions in the aforementioned Health Unit, but which were not included in the national program, resulting a total of 73 reconstructive surgical interventions. The research results show that the overall rate of complications was 43.83%, skin necrosis, superficial infection and seroma being in this order the main complications that were identified. In the authors opinion, risks of complications are moderated in relation with breast reconstruction surgery. However, the complication rate significantly varies depending on the chosen technique. The lowest risk levels registered in this study were associated with the breast reconstruction using the two-stage expander-implant technique. The analysis compares the achieved results with data provided by international studies, the main differences being caused by the status of the medical infrastructure, as well as the moment of hospital admission that is primarily determined by the level of medical education.

Corresponding author: Catalin-Gheorghe Bejinariu, MD; e-mail: drbejinariu@gmail.com

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9. Immunohistochemical study of experimentally drug-induced gingival overgrowth

Stefania Craitoiu, Adelina Gabriela Bobic, Horia Octavian Manolea, Mihaela Cezarina Mehedinti, Roxana Maria Pascu, Alma Maria Florescu, Ileana Cristiana Petcu, Andrei Osman, Cristina Mihaela Farcas-Berechet, Monica Mihaela Iacov-Craitoiu

The increasing frequency of using in the medical practice drugs that have the potential to induce gingival overgrowth (GO) and the existence of many unknown aspects in GO etiopathogenesis have prompted us to carry out this immunohistochemical experimental animal study. We conducted a cell proliferation study by Ki67 immunostaining and a cytokeratin (CK) study using anti-pan-CK AE1/AE3 and anti-MNF116 antibodies, investigating the differences induced by different classes of drugs that are more frequently involved in the induction of GO. The results of our study indicate that CK AE1/AE3 plays an important role not only in normal cellular proliferation, but also in hypertrophic tissues, and can be considered a marker of the proliferative process occurring in GO. Immunostaining for the anti-MNF116 antibody was weaker and inconsistent in intensity compared to anti-CK AE1/AE3 antibody, its staining pattern appearing as diffuse or zonal.

Corresponding author: Andrei Osman, Assistant Professor, MD, PhD; e-mail: andreiosman3@gmail.com

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10. Multiple versus unifocal breast cancer: clinicopathological and immunohistochemical differences

Andrian Panuta, Iulian Radu, Bogdan Gafton, Nicolae Ioanid, Cristina Terinte, Dan Ferariu, Mihaela Buna-Arvinte, Dragos Viorel Scripcariu, Viorel Scripcariu

Multiple breast cancer (MBC) is a controversial topic due to the lack of a consensus regarding its definition, classification issues and imprecise management recommendations in current reference guidelines. In four years, 756 patients with breast cancer (BC) were surgically treated in our Unit, 91 (12.03%) of them being pathologically diagnosed as MBCs. We present the results of our retrospective case-control study that performed a comparison between the clinicopathological characteristics and immunohistochemical (IHC) profiles of our MBC group versus a control group, represented by a sample of 184 cases randomly chosen from those with unifocal breast cancer (UBC). Starting from the premise of increased biological aggressivity of MBC, showed by several reports, we proposed to research the possible differences between these groups and to highlight their potential predictive and/or prognostic value. We found that MBC patients have a poorer prognosis than UBC ones - younger age at diagnosis [more cases less than 50 years old (p=0.03)], a lower frequency of T1 and a higher rate of T3 tumors [when using aggregate tumor size measuring method (p<0.001)], fewer node-negative (N0) cases (p=0.046) and a higher frequency of mucinous breast carcinoma (p=0.026). It worth mentioning that we obtained lower rates of poorly differentiated (G3) tumors (p=0.022) in the MBC group, this result being opposite to those found by other researchers. Our study also revealed a higher rate of human epidermal growth factor receptor 2 (HER2/neu)-type cases in MBC group (p=0.022), these patients having the chance to benefit from treatment with monoclonal antibodies, with a better outcome than patients with triple-negative type. We registered significantly lower progesterone receptor (PR) positivity rates in patients with MBC, thus having a negative predictive value by showing a worse response to hormone-based therapies. Besides, we found heterogeneity of IHC features among tumor foci in MBC that may influence the therapeutic decisions. Our results sustain that MBC is biologically a more aggressive type of mammary neoplasia requiring a more particular therapeutic approach.

Corresponding author: Iulian Radu, Lecturer, MD, PhD; e-mail: raduiuli@gmail.com

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11. Histological findings from rat calvaria defect augmented with platelet-rich fibrin by using two consecutive periosteal incisions

Alexandru Florian Grecu, Dragos George Popa, Cristian Virgil Lungulescu, Eduard Mihai Ciuca, Adrian Camen, Daniela Marinescu, Oliviu Nica, Cristina Jana Busuioc, Feng Ifrim Chen, Marius Eugen Ciurea

Background and Objectives: Platelet-rich fibrin (PRF) is a new generation of biomaterial that proved to be an effective tool in numerous clinical uses. This study aims at expanding the range effectiveness of PRF in promoting bone healing by histological evaluation. Materials and Methods: We performed a pair of two calvaria defects on 35 Wistar rats. The left defect was left empty as a control and the right defect was augmented with PRF. After 45 days, the experiment was terminated and the calvaria were collected and underwent morphological and histological analysis. Results: New bone formations have been shown to be prevalent in the PRF augmented defect. Conclusions: PRF increases the body s natural ability to heal and regenerate bone.

Corresponding author: Oliviu Nica, PhD Student; e-mail: oliviu.nica@gmail.com; Feng Ifrim Chen, Associate Professor, MD, PhD; e-mail: adsm.adsm@yahoo.com

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12. Immunoexpression of MMP-8, MMP-9 and TIMP-2 in dilated cardiomyopathy

Radu Mitrut, Alex Emilian Stepan, Claudiu Margaritescu, Bianca Catalina Andreiana, Ana Maria Kesse, Cristiana Eugenia Simionescu, Constantin Militaru

Alteration of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) expression has been studied for various cardiac diseases, including dilated cardiomyopathy (DCM), with the significance of surrogate markers of extracellular matrix (ECM) remodeling. In this study, we determined the MMP-8, MMP-9 and TIMP-2 immunoexpression in the heart of patients diagnosed with DCM in relation to a histological composite score (HCS). The study included 40 cases of heart fragments that were processed by the usual paraffin inclusion technique, followed by a semi-quantitative evaluation of histopathological parameters, which summed, allowed the establishment of a HCS. Subsequently, the cases were immunohistochemically processed for MMP-8, MMP-9 and TIMP-2, followed by the semi-quantitative evaluation of their expression intensity. MMP-8 was identified only in myocardiocytes, while MMP-9 and TIMP-2 were present in both myocardiocytes and stroma, but with different intensity. The increasing intensity of MMP-8 and TIMP-2 immunoreactions was significantly associated with low HCS. In case of MMP-9, the immunostaining intensity analysis in relation to the HCS level revealed insignificant differences, but we found an association of increased and moderate intensity with low HCS. The imbalance between TIMPs and MMPs disrupts the ECM architecture and contributes to the remodeling process in DCM, aspect that can be used in the development of new clinical therapies.

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

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13. Co-morbidities in the multiple victims of the silent killer in carbon monoxide poisoning

Camelia-Oana Muresan, Roxana Eugenia Zavoi, Raluca Oana Dumache, Cris Virgiliu Precup, Veronica Ciocan, Ovidiu Stefan Bulzan, Charoula Florou, Alexandra Enache

Carbon monoxide (CO) remains an insidious and silent killer due to its physical and chemical properties; its lethal effects are encountered in cases of household accidents, occupational hazards or suicide. Deaths due to CO poisoning were studied retrospectively in the period 2000-2018 at the Institute of Forensic Medicine, Timisoara, Romania. These cases represent 1.75% of all the autopsies and 0.63% of all violent deaths. There have been cases of single deaths and cases with multiple victims - concomitant deaths. The analysis of lethal CO intoxication cases that occurred in different circumstances (incomplete burning with CO accumulation, fires - associated with burns, death in the fountain - due to fossil fuel pump failure, suicide due to exhaust gases) was based on the examination of 298 autopsy files. In this type of poisoning, the forensic examination of the body is marked by the non-specific character of most of the macroscopic and microscopic changes. Although inconstant, these types of changes (e.g., red discoloration of livor mortis) raise the suspicion of death by CO poisoning; the essential contribution to establishing cause of death resides in the determination of carboxyhemoglobin (COHb) concentration by spectroscopy. In all cases, the cerebral and cardio-pulmonary modification and their contribution to the cause of death were studied. Co-morbidities interfere with the cause of death in cases with average COHb concentrations, in the 20-50% range, where CO blood levels alone are not reason enough to explain the onset of death.

Corresponding author: Roxana Eugenia Zavoi, Professor, MD, PhD; e-mail: roxanazavoi@yahoo.com; Veronica Ciocan, Associate Professor, MD, PhD; e-mail: veronica.luta@gmail.com

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14. Microscopic aspects of junction between dental hard tissues and composite material depending on composite insertion: layering versus bulk-fill

Ruxandra-Ilinca Matei, Liana Todor, Emilia Albinita Cuc, Mihai Raul Popescu, Lucian Paul Dragomir, Anne-Marie Rauten, Anca Porumb

Polymerization stresses in adhesive structure could determine an adhesive or cohesive failure and interfacial gaps forming. Some clinical procedures - as light curing composite resin layering in 2-3 mm increments (especially for dental fills) or using dental reconfiguring clear acetate crowns - are sat up to combat (in some way) the polymerization shrinkage. This study approaches the manner how clinical dental adhesive application could influence the hard dental tissues-composite materials interface. The sample studied consisted of 12 upper bicuspids, extracted for orthodontic reasons. In our study, we chose the adhesion technique in two steps. We prepared enamel and dentine areas, and then filled them with light-polymerization composite. After that, the teeth were subject of microscopic investigations, at 100x and 200x magnification. As conclusion of our study, we sustain that light curing composite resin applying clinical technique (by layering or with acetate crown) might influence a good dental restoration clinical performance.

Corresponding author: Liana Todor, Lecturer, DMD, PhD; e-mail: liana.todor@gmail.com; Lucian Paul Dragomir, Lecturer, DMD, PhD; e-mail: dragomirlucianpaul@yahoo.com

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15. Clinical relevance and accuracy of p63 and TTF-1 for better approach of small cell lung carcinoma versus poorly differentiated nonkeratinizing squamous cell carcinoma

Daniela Gurgus, Mirela Loredana Grigoras, Andrei Gheorghe Marius Motoc, Carmen Lacramioara Zamfir, Marioara Cornianu, Cosmin Ioan Faur, Daniel Laurentiu Pop, Roxana Folescu

Lung cancer high mortality rate remains a major problem, despite the actual progress in its early detection and therapeutic design. Since lung cancer treatment requires separation of tumors in small cell carcinoma and non-small cell carcinoma, the histopathological diagnosis focuses on this basic distinction, while immunohistochemistry contributes considerably to confirm the diagnosis accuracy. In order to check the assumption that p63 is a useful marker for squamous cellular differentiation, we used two antibodies: anti-p63 and anti-thyroid transcription factor-1 (TTF-1), based on their immunoexpression to differentiate small cell lung carcinoma (SCLC) from poorly differentiated nonkeratinizing squamous cell carcinoma (SCC). Our study included 48 cases of lung carcinoma (lung biopsies and wedge resection formalin-fixed and paraffin-embedded). The 48 cases included 23 SCLCs and 25 poorly differentiated nonkeratinizing SCC. The expressions of p63 and TTF-1, respectively, proved to be useful in distinguishing SCLC from poorly differentiated nonkeratinizing SCC, on surgical and biopsic sections. The p63 positivity and TTF-1 negative expression consequently indicated a poorly differentiated nonkeratinizing SCC, while the opposite immunostaining pattern was flagged in SCLC. Our results are useful for a targeted therapy, as long as they point out a significant role in marking of the correct diagnosis of lung tumors.

Corresponding author: Mirela Loredana Grigoras, Assistant Professor, MD, PhD; e-mail: mirela.grigoras@yahoo.com

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16. The potential curative and preventive effects of garlic on testosterone-induced benign prostatic hyperplasia in orchiectomized rats

Wael Amin Nasr El-Din, Islam Omar Abdel Fattah

Benign prostatic hyperplasia (BPH) is a common aging disease in men. Garlic is known to have anti-proliferative effects. Therefore, this study was designed to investigate the curative and preventive effects of garlic on BPH in rats. Rats were divided into five groups: control group, orchiectomized group (where rats were subjected to bilateral orchiectomies operation), BPH group [BPH was induced by intramuscular injection of testosterone (TE) enanthate once weekly for five weeks after orchiectomy], curative group (where rats were injected with TE for five weeks followed by daily administration of garlic powder for other five weeks), and preventive group (where rats were given garlic powder simultaneously with TE injections for five weeks). Serum levels of TE and prostate-specific antigen (PSA) were measured, and prostate weighed and processed for light microscopic, immunohistochemical and transmission electron microscopy (TEM) examination. Serum levels of TE and PSA, and prostate weight (PW) were significantly increased in BPH group and significantly decreased in curative and preventive ones. Histologically and morphometrically, BPH group showed epithelial hyperplasia, stromal expansion and reduced acinar lumens that were significantly improved in both curative and preventive groups. Proliferating cell nuclear antigen (PCNA) expression was increased while caspase-3 expression was decreased in BPH group. These results were reversed in both curative and preventive groups. TEM showed nuclear irregularities, dilated endoplasmic reticulum (ER) cisterns, and lost cell boundaries, secretory vesicles and apical microvilli. Most of the previous changes were minimized in preventive group more than in curative one.

Corresponding author: Wael Amin Nasr El-Din, Assistant Professor; e-mail: waelamin2010@yahoo.com

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17. Visual criteria in small bowel tumors detected by capsule endoscopy - morphological description and correlations with histological type

Ana-Maria Singeap, Anca Trifan, Catalin Sfarti, Stefan Chiriac, Laura Huiban, Carol Stanciu, Mihai Danciu

Introduction: Small bowel tumors (SBTs) are rare. The advent of small bowel capsule endoscopy (SBCE) revolutionized the diagnosis of small bowel pathology, the SBCE major breakthrough consequently doubled the diagnostic rate of SBTs. Being a visual technique, without ability to take biopsies, SBCE has limitations in the diagnostic work-up of SBTs. Aim: To assess if structured visual description of SBTs detected by SBCE correlates with the histological type. Patients, Materials and Methods: We included patients with SBTs, evaluated by SBCE and furthermore explored, for which a final histopathological diagnosis was made, either on biopsy tissue samples, or on surgical specimens, using routine techniques and immunohistochemistry. The SBCE findings and reports were reviewed in order to assess the main macroscopic features of the SBTs, which were further correlated with the histological type. Results: SBTs frequency at SBCE was 5.2%. All SBTs presented as protruding lesions. Features as size, color, type, shape, discoloration, presence of mucosa ulceration, bleeding stigmata or potential, contributed outlining a prototype. SBCE was accurate in terms of localization and suspected diagnosis. Conclusions: Even if SBCE is a purely visual technique, thorough examination and rigorous analysis of macroscopic features, as well as adoption of a structured terminology, may successfully predict the final diagnosis, empowering SBCE not only as a trust comrade in the diagnostic pathways of SBTs, but also as a valuable standalone technique mandating the final therapeutic decision.

Corresponding author: Anca Trifan, Professor, MD, PhD, FRCP; e-mail: ancatrifan@yahoo.com

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18. Complex evaluation in patients with knee osteoarthritis

Magdalena Rodica Traistaru, Diana Kamal, Daniela Teodora Maria, Marian Valentin Zorila, Dragos Ovidiu Alexandru, Otilia Constantina Rogoveanu, Mirela Radu, Kamal Constantin Kamal

Knee osteoarthritis (KOA) is a very common, slowly progressive and incurable articular disease resulting in the breakdown of cartilage and bone in the joint, which causes significant discomfort, pain and disability, with a significant socio-economic impact. The aim of our observational study for patients with symptomatic KOA was to investigate the changes of C-terminal telopeptide of type II collagen (CTX-II) in serum pre and post a complex rehabilitation program and to establish the correlation between all studied parameters [clinical, functional, serum CTX-II (sCTX-II) and histological aspects obtained through arthroscopy]. During 2016-2017, we performed an observational study including 24 patients, between 59 and 76 years old, diagnosed with KOA. Studied patients were completely assessed before (T1) and four months after a complex rehabilitation program (T2). The measured parameters were stiffness, pain, and physical function and we used the Visual Analogue Scale (VAS) for pain, with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), sCTX-II value obtained by enzyme-linked immunosorbent assay (ELISA) test, histological assessment of knee cartilage after arthroscopy. In the histological assessment of our patients, we observed that the cells of the superficial areas were round and hypertrophic, the cartilage tissue had few proteoaminoglycans and glycosaminoglycans, with an airy aspect of the matrix and degenerate cells, numerically reduced. After positive diagnosis, the complete treatment, including the rehabilitation program, seems to be the ideal option for improving the CTX-II values, as well as the quality of life in KOA patients.

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

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19. Correlations between morphology of cervical vertebrae and dental eruption

Luminita Ligia Vaida, Abel-Emanuel Moca, Liana Todor, Adriana Tent, Bianca Ioana Todor, Bianca-Maria Negrutiu, Alina Iren Moraru

The process of dental eruption is submitted to physiological and pathological variables. A series of discrepancies may occur, one of these being a disturbance between dental age and bone age. The assessment of bone age is best made with the cervical vertebral maturation (CVM) method, simplified by Baccetti et al. (2005). The sample studied consisted of 215 orthodontic patients. The dental age was assessed on the orthopantomograph radiographies and the bone age on the lateral cephalograms. For determining the bone age, CVM method was used. Considering dental age, most of the patients (50.2%) have a premature dental age compared to bone age, while patients with normal dental age (27.9%) and patients with late dental age (21.9%) have a lower frequency. The correlation between the dental age and the bone age of the patients shows that patients who have higher values of dental age also have higher values of bone age (p<0.001). The correlation between genders shows that female patients tend to have a higher average value of bone age in comparison to male patients (p<0.001). The authors conclude that assessing bone age based on the morphology of cervical vertebrae and correlating it with the dental age could be of great use in opting for a certain orthodontic treatment plan.

Corresponding author: Liana Todor, Lecturer, DMD, PhD; e-mail: liana.todor@gmail.com; Adriana Tent, Assistant, DMD, PhD; e-mail: adriana.tent@yahoo.com

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20. Interrelations between elevated alpha-fetoprotein levels and tumor morphology of patients with hepatocellular carcinoma

Elena Toader, Andrei Bancu, Dana Elena Mitrica, Gabriel Constantinescu, Gabriela Stefanescu, Gheorghe G. Balan

Background: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer related deaths worldwide, while at the same time having a constant growth in incidence. A commonly used biomarker in managing liver cancer cases, alpha-fetoprotein (AFP) is losing clinical ground in favor of imaging studies and emerging biomarkers. The study aims to reassess potential prognosis indicators and risk factors for an elevated level of this glycoprotein by analyzing its relationship with macroscopic morphology tumor-related features. Patients, Materials and Methods: One hundred and thirty-one newly diagnosed HCC patients had their clinical, tumor and liver disease features investigated in contrast to elevated AFP levels with 200 IU/mL being used as preferred cut-off. Results: Tumor size >=5 cm [odds ratio (OR) 3.36, 95% confidence interval (CI): 1.29-8.74, p=0.013] is an independent tumor-related predictor of markedly elevated AFP values. Noteworthy connections with the type of tumor, multinodular appearance and portal vein thrombosis were also found through univariate analysis. Conclusions: AFP could still be a reliable tool in diagnosis and prognosis of HCC patients especially in developing countries due to its relevant association with aspects of advanced tumor and liver disease, gender and a poor functional status.

Corresponding author: Andrei Bancu, MD; e-mail: andrei.bancu92@gmail.com

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21. Biochemical and histological effects of embryonic stem cells in a mouse model of renal failure

Gustavo Jesus Vazquez-Zapien, Adriana Martinez-Cuazitl, Laura Susana Rangel-Cova, Alejandro Camacho-Ibarra, Monica Maribel Mata-Miranda

Kidney diseases are a global public health problem. Despite significant advances in the understanding of renal failure (RF) and replacement therapies, this condition carries a series of complications and the life s quality of patients decreases. Differentiation capability of stem cells and their beneficial effects when they are implanted in animal models have been reported. Therefore, this work aimed to induce a long-term RF in mice, evaluating the biochemical and histological effects after implanting mouse embryonic stem cells (mESC). Mice were subjected to renal failure induction (RFI) employing cisplatin, subsequently received intraperitoneal (i.p.) injections of salt solution (control group, n=19) or 50 000 mESC (experimental group, n=19) at 24 hours, 7 days, and 13 days post-RFI. Ten animals in each group were used to analyze functional damage through serum biochemical analysis, and the mortality. For histopathological examination, three animals of each group were sacrificed at 5, 10, and 20 days post-RFI, analyzing the tubular system and glomeruli. Both groups showed blood urea nitrogen (BUN) and creatinine elevation three days post-RFI. Accumulated mortality was lower in the experimental group, presenting statistical significance. Respect to histopathological effects, the control group showed tubular dilatation, segmental focal glomerulosclerosis data, and collapsed glomeruli, while in the experimental group, glomerulosclerosis or collapsed glomeruli were not observed, evidencing regenerative data as characterized by large nuclei with prominent and binucleate nucleoli. In conclusion, mESC implant in mice with RFI significantly decreased the mortality, avoiding a greater histological deterioration related to the disease.

Corresponding author: Monica Maribel Mata-Miranda, Dr, MD, PhD; e-mail: mmcmaribel@gmail.com

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22. Correlations between clinical and placental histopathological and immunohistochemical features in women with and without hereditary thrombophilia

Janina Georgiana Nacea, Ionela Rotaru, Mihaela Niculescu, Radu Stanescu, Nicolae Cernea, Ana-Maria Patrascu, Loredana Elena Stoica, Stefania Tudorache

Aim: The primary objective of this study was to correlate hereditary thrombophilia (high- or low-risk) with specific placental histopathological (HP) and/or immunohistochemical (IHC) changes, for confirming/ruling out a possible linkage between these two biological parameters. Patients, Materials and Methods: We present a 3-year prospective study conducted between 2016 and 2019 that enrolled 90 women registered in two Clinics of Obstetrics and Gynecology in Craiova, Romania, with personal thrombotic and/or pathological obstetrical history. The HP and IHC analysis of the placenta was performed using monoclonal anti-cluster of differentiation 34 (CD34) antibody, anti-hypoxia-inducible factor-1 alpha (HIF-1alpha) and anti-endothelial nitric oxide synthase (eNOS) antibody. Results: There was a high incidence of all thrombophilia (TPh) mutations in Caucasian women with thrombotic and obstetrical complications. Among them, both HP and IHC examination revealed significant changes. These were more severe in the placentas of patients with homozygous Factor V Leiden (FVL) gene mutation and double heterozygous FVL/PII gene mutation. Multiple placental infarctions with massive fibrinoid necrosis and an increase in syncytial knots are common findings. In the same group, we found by means of IHC examination - intense positive HIF-1alpha and eNOS immunoexpression, and low positive CD34 expression, especially in fibrinoid necrosis and thrombosis areas. We found no correlation between clinical, HP and IHC changes in patients with low-risk TPh or without TPh. Conclusions: Among patients with obstetric and thrombotic complications, there is a high prevalence of TPh. It appears that hypercoagulability reported in high-risk thrombophilia (HR-TPh) has major effects on placental tissue (fibrinoid necrosis, multiple thromboses, hypoxia and oxidative stress). Significant placental changes were found predominantly in women with HR-TPh. Strategies for TPh screening based on HP/IHC pattern would be, most probably, more cost-effective compared with the extended TPh testing offered in large populations. This way, a smaller number of patients will be tested and in this group a higher proportion of patients will be found as having HR-TPh mutations.

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

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23. What if body fat percentage association with FINDRISC score leads to a better prediction of type 2 diabetes mellitus?

Iulia-Elena Jurca-Simina, Iulius Juganaru, Mircea-Stefan Iurciuc, Stela Iurciuc, Emil Ungureanu, Andreea Iulia Dobrescu, Adela Chirita-Emandi, Oana Raluca Voinescu, Ioana-Cristina Olariu, Maria Puiu, Doina Georgescu, Veronica-Madalina Boruga

Introduction: Nowadays, the efforts regarding the prevention of type 2 diabetes mellitus (T2DM) are focused on decreasing overweight, obesity and visceral fat accumulation or percent body fat (PBF) risk factors. Aim: The aim of this study was to investigate whether use of bioelectrical impedance analysis (BIA) for measuring PBF could be a reliable method to improve risk assessment of T2DM. Participants, Materials and Methods: This cross-sectional study performed in 2016 enrolled 341 healthy medical students from western Romania, aged 18 to 44 years old, 143 females and 198 males. Anthropometric measurements, PBF (BIA machine InBody720) determination, along with the Finnish Diabetes Risk (FINDRISC) assessment form, were performed for each participant. Results: 27.6% of the entire cohort was determined as being overweighed and 12% obese. FINDRISC score showed that 5% from the entire group have a moderate to very high risk to develop T2DM in the following 10 years. FINDRISC score was correlated with waist-to-hip ratio (WHR) and PBF showing strong and positive correlations to both parameters (WHR: 0.477, p<0.001; PBF: 0.561, p<0.001). Discussions: Our results indicate a stronger correlation between FINDRISC score with PBF compared to FINDRISC and WHR for the entire cohort, and for both males and females. Conclusions: We recommend PBF measured by BIA (respecting quality control procedures) as a potential parameter to be considered into the risk model predictions for T2DM, as it is an accessible and affordable tool to use in the primary level of healthcare.

Corresponding author: Mircea-Stefan Iurciuc, MD, PhD; e-mail: mirceaiurciuc@gmail.com; Emil Ungureanu, MD, PhD; e-mail: mdemil@gmail.com

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24. Inflammation: predictive factor for negative evolution of prostate diseases

Adrian Silviu Crisan, Imola Miklos, Alin Ioan Grelus, Bogdan Dan Totolici, Carmen Neamtu, George Ciprian Pribac, Dragos Botezatu, Octavia Cornelia Vita, Ioan Ioiart

The most frequent prostate diseases depending on age are prostatitis in young men, benign prostate hypertrophy in men over 50 years old, and prostate cancer (PCa) in elderly patients. The purpose of our study is to evaluate the role of inflammation in the progression of prostate diseases. We used clinical and paraclinical techniques for the positive diagnosis [serum prostate-specific antigen (PSA) determination, we performed transrectal ultrasound to asses the prostate volume and prostate biopsy or transurethral resection of the prostate, where it was imposed]. The prostate tissue specimens were analyzed histopathologically and immunohistochemically. Our results show that PCa patients with higher inflammation rates had a higher Gleason score in both the castration-resistant prostate cancer (CRPC) group and the castration-sensitive group. We have noticed that patients with high inflammation grade also had a much higher International Prostate Symptom Score (IPSS). In conclusion, we can say that in our study, inflammation played an important role in the evolution of benign and malignant prostate diseases; its presence has influenced directly the severity of symptoms, and the aggressiveness of the diseases.

Corresponding author: Carmen Neamtu, Associate Professor, MD, PhD; e-mail: carmen.neamtu@gmail.com; Bogdan Dan Totolici, Professor, MD, PhD; e-mail: totolici_bogdan@yahoo.com

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25. Ghrelin-producing cells distribution in the stomach and the relation with Helicobacter pylori in obese patients

Laura Mihalache, Lidia Iuliana Arhire, Simona Eliza Giusca, Andreea Gherasim, Otilia Nita, Daniela Constantinescu, Razvan Nicolae Constantinescu, Sergiu Serghei Padureanu, Mihai Danciu

Objective: Ghrelin is believed to influence weight evolution after bariatric surgery. Helicobacter pylori (H. pylori) infection may influence ghrelin plasma levels by affecting the ghrelin-producing cells (GPC) in the stomach. The purpose of the study was to characterize the GPC distribution in the stomach in overweight patients and the influence of H. pylori infection on them. Patients, Materials and Methods: The study group included 21 obese patients undergoing bariatric surgery with ghrelin levels and anti-H. pylori antibodies previously measured, and upper gastrointestinal endoscopy with histological evaluation of H. pylori infection performed. Immunohistochemical expression of ghrelin was quantified in gastric resection specimens. Results: The results showed a higher number of GPC in the obese women than in men (p>0.05). The highest number of GPC was detected in the gastric body, followed by the fundus and antral region (p<0.001). GPC number correlated inversely with anthropometric parameters: weight (p=0.011), body mass index (BMI) (p=0.017), waist circumference (WC) (p=0.066) was lower in patients with H. pylori infection (p>0.05) or gastritis (p>0.05), the number decreasing with the increase in depth of gastritis lesion (p>0.05). Conclusions: The present study fulfills the characterization of GPC in obese patients, showing a higher number in women than in men, their predominant location in the gastric body, and their relationship with the anthropometric parameters (weight, BMI, WC), H. pylori infection and gastritis lesions. These results open broad perspectives for a deeper understanding of the ghrelin involvement in the obesity pathogenic mechanism, associated or not with other gastric conditions.

Corresponding author: Simona Eliza Giusca, MD, PhD; e-mail: simonaelizagiusca@gmail.com; Lidia Iuliana Arhire, MD, PhD; e-mail: lidia_graur@yahoo.com

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26. Morphopathological particularities of cerebrovascular diseases for patients in the northeastern area of Romania

Iulian Dan Cuciureanu, Marius Valeriu Hinganu, Cristian Statescu, Anca Sava, Delia Hinganu, Mihaela Dana Turliuc, Tudor Cuciureanu, Radu Andy Sascau

Cerebrovascular diseases (CVD) are pathologies caused by the primary or secondary damage of one or more arteries supplying the brain. Our study aims to create a link between the modifiable risk factors, the affected vascular territory and the clinical manifestation of CVD in patients from our geographical area. Our study proposes the retrospective analysis of a group of 70 patients diagnosed with ischemic stroke with spontaneous hemorrhagic transformation over a period of five years, between April 1, 2015 and April 1, 2018, admitted in the 1st Neurology Clinic, Prof. Dr. Nicolae Oblu Clinical Emergency Hospital, Iasi, Romania. The pathology of strokes is determined by risk factors and comorbidities, which have a clear demographic pattern. The existence of a correlation between demographic risk factors of CVD and the clinical manifestation allows for the individualization of a clinical examination protocol leading to a rapid diagnosis.

Corresponding author: Marius Valeriu Hinganu, University Lecturer, MD, PhD; e-mail: hanganu.marius@yahoo.com; Cristian Statescu, University Lecturer, MD, PhD; e-mail: cstatescu@gmail.com

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27. Suspicions of titanium allergic reaction influencing the prosthetic solution in a rare case of implant flowering

Oana-Cella Andrei, Livia Alice Tanasescu, Mihai Burlibasa, Marilena Bataiosu, Luminita Daguci, Liliana Burlibasa, Adina Andreea Turcu, Constantin Daguci

The aim of this paper is to eliminate suspicions of a titanium (Ti) allergy in a rare case of flowered implant in a 43-year-old female patient with metal allergies and no history of bruxism, using a histological and immunohistochemical (IHC) analysis to determine the phenotype of cells that participated in the immune response; also, to assess the prognosis of a future implant treatment and to highlight the psychological impact of osseointegrated implant failure caused by fracture, and the influence that the necessity to use extensive surgical procedures for reimplantation can have on the treatment solution chosen by the patient. The results of our IHC analysis did not indicate a clear response for a potential Ti allergy; still, due to psychological reasons, the patient rejected the replantation and considered the use of other restorative option, a three-unit bridge, as being the most appropriate for her. Considering her opinion and attitude, the fixed prosthetic denture assured the therapeutic success.

Corresponding author: Luminita Daguci, Associate Professor, DMD, PhD; e-mail: daguciluminita@yahoo.com; Livia Alice Tanasescu, Assistant, DMD, PhD; e-mail: tanasescualice@gmail.com

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28. Epithelial-glial transition in an atypical meningioma - a case report

Gabriela-Camelia Rosu, Ionica Pirici, Alex Emilian Stepan, Oana Taisescu, Mihaela Carmen Patruleasa, Laurentiu Mogoanta, Otilia Clara Margaritescu

Atypical meningiomas with a mixed glial-epithelial phenotype are rare reports, and here we described an aggressive case on which double immunofluorescence ascertained the co-expression of epithelial membrane antigen (EMA) with glial fibrillary acidic protein (GFAP) in the same tumor cells. A 62-year-old female presented with acute intracranial hypertension symptoms occurred over the last 24 hours, muscle weakness on the right side, cerebellar dysarthria, and wide base gate. Magnetic resonance imaging (MRI) examination showed a right cerebellar hemisphere non-homogenous tumor, with intense gadophylia, diffuse contours, and necrotic inner areas. There were also scar-like areas at the level of the left cerebellar hemisphere, and the patient recalled a previous surgical intervention at the age of 6 years old without further diagnostic data. The patient suffered an ischemic event in the brain stem and died shortly after the surgical removal of the tumor. Histopathology revealed an epithelial-like tumor with moderately pleomorphic and elongated cells arranged in fascicles, rare necrotic areas, and a few proliferating multilayered vessels structures. Immunohistochemistry (IHC) revealed variable EMA positivity, intense vimentin staining, rare GFAP-positive intra-tumor areas, a moderate expression for cytokeratin 8/18, reduced labeling for an anti-progesterone receptor (PrgR) antibody, cluster of differentiation (CD) 10 negativity, and a high Ki-67 proliferating index of around 40%. The case was deemed as an atypical meningioma, and interestingly, a double IHC for GFAP/EMA revealed a strong colocalization of the two markers in the tumor mass. Although extremely rare, the reports of meningiomas expressing a mixed epithelial/glial profile might be connected with their aggressive evolution. Double IHC might help in predicting the evolution of these cases and determine which patients should benefit from closer surveillance.

Corresponding author: Ionica Pirici, Lecturer, MD, PhD; e-mail: dana.pirici@yahoo.com; Oana Taisescu, Lecturer, MD, PhD; e-mail: otaisescu@gmail.com

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29. Unusual extramedullary relapses in a case of common B-cell acute lymphoblastic leukemia. Case report and review of literature

Cristian Nicolae Sava, Ladislau Ritli, Andreea Bianca Balmos, Alin Remus Iuhas, Paula Marian, Monica Adriana Motorca, Laura Anca Lele, Oreste Straciuc, Dana Carmen Zaha, Maria Claudia Jurca, Larisa Niulas, Nicoleta Negrut

Background: Acute lymphoblastic leukemia (ALL) represents the most common malignancy in children with an overall cure rate of 85%. Relapses occur in 20% of the cases. Commonly, extramedullary relapses (EMRs) involve central nervous system (CNS) or testes. Unusual EMRs in ALL are relatively rare reported. Case presentation: The authors present a 24-year-old woman with ALL, who experienced three unusual EMRs. In 2007, she was diagnosed with B-cell precursor (BCP)-ALL - high-risk (HR) group, and she was treated according to ALL Intercontinental Berlin-Frankfurt-Münster (IC-BFM) 2002/HR Protocol. She entered complete remission (CR). In 2012, a vaginal wall solid mass infiltrate occurs. Biopsy concluded for EMR of ALL. Chemotherapy was restarted; the patient responded again with CR. Magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT) examinations during follow-up revealed supraclavicular, mesenteric, and retroperitoneal lymphadenopathies (2014). Pathological examination of the supraclavicular lymph node showed a benign pattern: schwannoma. The patient s evolution worsened, imposing a biopsy from the retroperitoneal tumor which revealed a second EMR of ALL. Again, ALL-REZ BFM 2002 Protocol was started, followed by haploidentical mother-to-child peripheral blood hematopoietic stem cell transplantation (HSCT). After suffering a few managed complications related to the transplant, our patient achieved CR again. In 2017, 10 years after the initial diagnosis, the patient presented for the third time an EMR (gastric wall) and eventually died due to progression of the disease. Conclusions: The patient presented an extremely aggressive type of ALL with three unusual EMRs: vaginal, retroperitoneal and gastric.

Corresponding author: Cristian Nicolae Sava, Lecturer, MD, PhD; e-mail: cristian.sava2004@gmail.com; Maria Claudia Jurca, Lecturer, MD, PhD; e-mail: claudiajurca70@yahoo.com

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30. Giant basal cell carcinoma of the nasal pyramid - case report

Danut Dinca, Loredana Elena Stoica, Luminita Gentiana Micu, Mariana Bardas, Gheorghe Raftu, Dilec Ionus, Elena Sapte

Basal cell carcinoma (BCC) is a frequent form of skin cancer, which usually affects people that have been exposed to the sunlight for longer periods of time. The cells of the lower part of the epidermis are called the basal cell layer. These cells constantly divide to form new cells to replace the squamous cells that wear off the skin s surface. As these cells move up in the epidermis, they get flatter, eventually becoming squamous cells. Therefore, the BCC develops from these cells. Most BCCs have indolent behavior, with cure rates very high after low-complexity treatment. However, some lesions are very aggressive and there are only a few papers focusing on the subtype of this skin cancer known with the name ulcus rodens or giant BCC. In this study, we evaluate a case of ulcus rodens or giant BCC, subtype of the BCC skin cancer located in the area of the nasal pyramid, stage III, TxNxMx, with lymphatic and vascular invasion present.

Corresponding author: Dilec Ionus, MD; e-mail: ionusdilec@gmail.com; Gheorghe Raftu, Associate Professor, MD, PhD; e-mail: gheorgheraftu@yahoo.com

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31. Two case reports of vertical and horizontal augmentation with autogenous bone blocks; seven years follow-up

Cristian Adrian Ratiu, Adina Bianca Bosca, Simona Cavalu, Emilian Hutu, Michael Vitzu, Gabriela Ciavoi

The current very high success rate of dental implants osseointegration has led to patients having increasingly high expectations in regards to aesthetic outcomes; therefore, effective management of soft tissues and healing of attached gingiva and papillae are essential in the effort to obtain satisfying aesthetic results for the patient. Obtaining papillae to address aesthetic requirements cannot be accomplished without bone reconstruction; an adequate volume of bone is essential in providing necessary long-term dimensional stability. The aim of this work was to highlight the advantages of autogenous bone grafting combined with plasma rich in growth factors (PRGF) in order to improve healing and reduce dehiscence risks. Two clinical cases were presented, both with important (horizontal and vertical) bone loss: in the first case, bone augmentation was performed at the same time as tooth extraction with no surgery needed for reconstruction of dental papillae, keratinized and attached mucosa; in the second case, vertical augmentation was performed by placing the bone graft in contact with an uninfected tooth. In both cases, aesthetic outcomes were as desired at the completion of treatment and also satisfactory at seven years follow-up.

Corresponding author: Adina Bianca Bosca, Lecturer, DMD, PhD; e-mail: biancabosca@yahoo.com; Michael Vitzu, DMD, Doctoral Candidate; e-mail: dr_mikael86@yahoo.com

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32. Primary tonsillar tuberculosis - case report

Nicolae Constantin Balica, Marioara Poenaru, Maria Alexandra Preda, Eugen Radu Boia, Ovidiu Nicolae Burlacu, Ioana Delia Horhat, Carmen Aurelia Mogoanta, Alexandru Nicolae Vlaescu, Flavia Baderca, Emilia Manuela Jifcu, Cristian Andrei Sarau

We report the case of a 44-year-old male patient with tonsillar tuberculosis (TB) diagnosed in the Department of Ear, Nose et Throat (ENT), Victor Babes University of Medicine and Pharmacy, Timisoara, Romania. The patient addressed to our Clinic with intense odynophagia, referred otalgia, sore throat, fever periods and weight loss. During the ENT clinical exam, we identified an enlarged left tonsil, partially covered with yellowish-white plaque, with ulceration and bleeding spots localized on tonsillar inferior pole. A high suspicion of tonsillar malignancy was raised, and a biopsy was performed revealing extrapulmonary TB. Taking into consideration the normal chest X-ray, a primary tonsillar TB diagnosis was established. The patient was addressed to Department of Pneumophthisiology for anti-tuberculous therapy for six months. At the end of the treatment, the patient was symptoms-free.

Corresponding author: Ioana Delia Horhat, Assistant Professor, MD, PhD; e-mail: deliahorhat@yahoo.com; Carmen Aurelia Mogoanta, Lecturer, MD, PhD; e-mail: carmen_mogoanta@yahoo.com

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33. A rare case of mitochondriopathy with autosomal dominant progressive external ophthalmoplegia diagnosed through skeletal muscle biopsy

Alexandra Eugenia Bastian, Gheorghita Jugulete, Emilia Manole, Luminita Alexandra Oprisan

Mitochondriopathies are a heterogeneous group of genetic diseases of all ages, with a very diverse clinical presentation related to genetic heteroplasmy. The clinical symptoms display a large variability and generally, the more severe phenotypes have an early onset, even from the neonatal period, while milder ones are manifested later in the adulthood. Most publications have already demonstrated deletions or point mutations in mitochondrial deoxyribonucleic acid (DNA), but in recent years, the field of investigation has expanded to syndromes caused by mutations in the nuclear DNA (nDNA), with a Mendelian inheritance. We present the case of a male patient with a mitochondriopathy with phenotype of chronic progressive external ophthalmoplegia (PEO), due to an autosomal dominant mutation in nDNA, in the DNA polymerase subunit gamma (POLG) gene, the pathogenic variant c.2864A>G (p.Tyr955Cys), morphologically investigated and diagnosed using a skeletal muscle biopsy. The aim of this presentation is to emphasize the diagnostic value of the muscle biopsy both in cases of clinical suspicion and in more challenging cases of mitochondrial diseases with atypical or unusual features. Although genetic testing may be the initial test of choice in cases with suggestive clinical presentation, muscle biopsy is an alternative diagnostic aid with high value even in our molecular era. We present pathological and ultrastructural data to confirm the diagnosis.

Corresponding author: Emilia Manole, Senior Researcher, PhD; e-mail: emilia_manole@yahoo.com

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34. The importance of the histopathological examination in establishing the diagnosis of delayed splenic rupture. Report of a case and literature review

Camelia Liana Buhas, Gabriel Constantin Mihalache, Claudia Teodora Judea-Pusta, Lucia Georgeta Daina, Gabriela Mutiu, Bogdan Adrian Buhas, Amorin Remus Popa, Maria Claudia Jurca, Nicolae Dumitru Nicoara, Adrian Marius Maghiar

In forensic activity, splenic ruptures occur frequently in cases involving abdominal trauma due to road traffic collision, strokes, falls and work accidents. Splenic lesions can occur either immediately after the trauma or within variable timeframes after it, the last scenario being the case of a delayed splenic rupture. Delayed splenic rupture is ranked third in abdominal traumatology frequency, after liver and intestine rupture. Delayed splenic rupture is more frequently the result of abdominal contusions or compressions, rather than the result of direct wounds located in the left flank. In the first stage, an intraparenchymatous hematoma is formed. The second stage occurs within a variable timeframe (between two days and one month), either spontaneously or following a second trauma, when the capsule ruptures leading to secondary peritoneal hemorrhage. In order to correctly determine the chronology of splenic lesions, histopathological (HP) investigations have an important role to play. The presence of hemosiderin highlighted by Hematoxylin-Eosin (HE) staining or special stainings, confirms the diagnosis of delayed splenic rupture. This study will present the case of a 55-year-old male from the countryside, a chronic alcohol consumer, animal care provider, who suffered multiple traumatic injuries four days prior to his death. He was found lying on the ground, presenting an open craniocerebral trauma (CCT) with a bleeding wound on the scalp. The autopsy showed CCT with meningeal hemorrhage and subdural hematoma, along with a splenic rupture presumably produced in two stages. The HP investigations did not reveal the presence of hemosiderin in the tested specimen samples. Using this scientific diagnostic criterion, it was thus confirmed that the splenic rupture occurred after the aggression, in another traumatic stage, the same one where the other thanatogenerator lesions occurred, as a result of the victim s collapse from the same level and hitting the planes with irregular surfaces.

Corresponding author: Claudia Teodora Judea-Pusta, Lecturer, MD, PhD; e-mail: claupustaml@yahoo.com; Lucia Georgeta Daina, Assistant Professor, MD, PhD; e-mail: lucidaina@gmail.com

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35. Primary malignant melanoma of the bladder - case report and literature overview

Gheorghe Adrian Bumbu, Mihail-Claudius Berechet, Ovidiu-Laurean Pop, Karim Nacer, Gheorghe Bumbu, Octavian Adrian Maghiar, Ovidiu Gabriel Bratu, Mihai Lucian Stefanescu, Carmen Pantis, Bogdan Andrei Bumbu

Malignant melanoma is one of the common skin cancers but as a primary cancer localized in urinary bladder is a very rare clinical entity, 0.2% of all melanomas. We report the very rare case of primary malignant melanoma of the bladder in an 80-year-old man. According with our knowledge is the first case of primary malignant melanoma reported in Romania. Only a few percent of malignant melanoma have origin outside the skin. Less than 30 cases of primary bladder melanoma have been reported in the literature. The most common metastasis in urinary bladder comes from breast carcinoma and skin melanoma The tissue examination presents the same futures does not matter if is a primary or secondary malignant melanoma. The ancillary tests like immunohistochemistry help us to do an accurate diagnostic but to discriminate primary vs. metastatic tumor remain an important issue. Usually, the bladder melanoma has an aggressive lethal behavior. Histopathological examination, immunohistochemistry, clinical history, and endoscopic evaluation can provide certain diagnostic features.

Corresponding author: Carmen Pantis, Lecturer, MD, PhD; e-mail: pantisc@gmail.com; Ovidiu-Laurean Pop, Associate Professor, MD, PhD; e-mail: drovipop@yahoo.com

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36. A case of giant cell tumor of the tendon sheath in an elderly patient: diagnostic difficulties and therapeutic options

Daniela Matei, Iulia-Rahela Marcu, George Laurentiu Patru, Liliana Patru, Adrian-Costin Bighea, Simona Patru

Giant cell tumor of the tendon sheath (GCTTS) is a benign tumor with a high recurrence rate of up to 50%. The lesion may appear anywhere in the synovium; the nature of this tumor is still controversial, however recent data shows that tenosynovial giant cell tumors (TGCTs) could be clonal neoplastic tumors. Most lesions of GCTTS produce one or more discrete nodules, while the radiological features can include soft-tissue masses with or without bone destruction. In an effort to advance in the understanding of GCTTS pathogenesis, we decided broadly investigate the immunophenotypic profile, of a TGCT in a 69-year-old female patient.

Corresponding author: Iulia-Rahela Marcu, MD, PhD; e-mail: rmarcu@gmail.com

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37. Monophasic sarcomatoid eccrine porocarcinoma. Report of a case and literature review

Jose-Fernando Val-Bernal, Marta Mayorga, Maria Martino, Sergio Sanchez-Santolino

Sarcomatoid porocarcinoma (SP) is a rare subtype of porocarcinoma composed of both malignant epithelial and sarcoma-like components. To our knowledge, only eight cases of this neoplasm have been published, all of them biphasic. A 42-year-old man presented with a latero-cervical nodule that had been noted for about five months. Histopathological study revealed an infiltrative tumor within the dermis and hypodermis without connection to epidermis, whose diagnosis was monophasic sarcomatoid eccrine porocarcinoma (SEP). The study of nine cases de SP, including the present, revealed that the ages of the patients ranged from 42 to 89 years (mean 72.3 years). There was no clear difference in the incidence with respect to gender. The location of the tumor was most common in the head and neck, followed by lower extremity. The size ranged from 2.5 cm to 3.5 cm (mean 3 cm). At the time of diagnosis, six (66.7%) lesions were ulcerated. No case was clinically diagnosed. Residual poroma was present in six (66.7%) cases. Only one case showed apocrine differentiation. Mitoses and comedonecrosis were frequent. Of the cases published, only four had a follow-up of at least 16 months. One patient succumbed to the tumor. We report for the first time a case of monophasic SEP without epidermal connection. The patient presented a regional lymph node metastasis three months after excision. The main differential diagnosis includes primary dermal melanoma and other rare variants of cutaneous melanoma, primary cutaneous clear cell sarcoma, primary cutaneous synovial sarcoma, and cutaneous metastasis from visceral sarcomatoid carcinoma.

Corresponding author: Jose-Fernando Val-Bernal, Professor, MD, PhD; e-mail: fernando.val@unican.es

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38. Colon cancer in pregnancy: a diagnostic and therapeutic challenge

Octavian Munteanu, Diana Voicu, Daniel-Iulian Voiculescu, Lucian Negreanu, Tiberiu Augustin Georgescu, Maria Sajin, Costin Berceanu, Claudia Mehedintu, Elvira Bratila, Anca-Maria Istrate-Ofiteru, Monica Mihaela Cirstoiu

Metastatic colorectal cancer during pregnancy and postpartum is rather rare, but it represents major diagnostic and therapeutic challenges for obstetricians and surgeons. Cancer itself rarely affects the placenta or growing baby directly. However, metastatic disease is much more common than in nonpregnant patients and detecting cancer while pregnant can be complicated for both the mother and the health care team. In this article, we report a case of moderately differentiated colon adenocarcinoma in pregnancy that was diagnosed in an advanced stage, implying a complex diagnostic and therapeutic approach. The classic histological and immunohistochemical (IHC) study on this case reveals that tumorous areas have lost goblet cells and, implicitly, mucus; also, there are absent estrogen and progesterone receptors, possible causes of neoplasm in pregnancy, the rate of tumor proliferation is increased, the IHC reaction that highlights the protein responsible for cytoplasmatic anchoring of cadherins is intense positive, and the enzyme responsible for inflammation and pain is increased in these areas.

Corresponding author: Costin Berceanu, Associate Professor, MD, PhD; e-mail: dr_berceanu@yahoo.com; Anca-Maria Istrate-Ofiteru, MD; e-mail: ancaofiteru92@yahoo.com

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39. Fatal Whipple s disease with severe mental manifestations on relapse - case report and brief advances update

George Saraci, Toader Zaharie, Gabriela Corina Zaharie, Stefan Cristian Vesa, Irina Ioana Visovan, Dan Gheban, Liliana Oana Pobirci

We present the case of a 51-year-old male admitted for asthenia, fatigability, nausea, inappetence, weight loss, watery diarrhea, lower limb paresthesia and diagnosed after further investigations with Whipple s disease (WD). The evolution was favorable under antibiotic therapy but after a period of time the patient was no longer compliant to the treatment and psychotic manifestations, general status alteration and finally the decease occurred. WD is a condition caused by Tropheryma whipplei (TW) bacterium in people with altered macrophage degrading capacity and it is lethal without early treatment.

Corresponding author: Dan Gheban, Lecturer, MD, PhD; e-mail: dgheban@gmail.com

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40. A rare association of cutaneous leukocytoclastic angiitis (hypersensitivity vasculitis) and hypersensitivity pneumonia (extrinsic allergic alveolitis) in a pigeon breeder - case report and literature review

Horatiu-Remus Moldovan, Nina Ionovici, Florina Nechita, Emoke Horvath, Edith Simona Ianosi, Eniko Gabriela Papp, Horatiu Valeriu Popoviciu, Gabriela Jimborean, Gabriela Moldovan, Maria-Ancuta Vlasiu, Simona Szasz

Extrinsic allergic alveolitis is an occupational condition intensively studied and published about, unlike cutaneous leukocytoclastic angiitis. The coexistence of these two diseases is even more rare in the same patient with exposure to occupational pollutants of animal origin. We present the case of a 44-year-old man, a pigeon breeder admitted to hospital with a pruritic purpuric eruption and lower limb paresthesia, dyspnea on exertion, polymyalgia rheumatica, mixed polyarthralgias. Based on the clinical, paraclinical and laboratory investigations (electroneuromyography, plethysmography, computed tomography scan, musculocutaneous biopsy, current laboratory tests and immunoassays), the main diagnoses of extrinsic allergic alveolitis and leukocytoclastic vasculitis were determined. The patient underwent treatment with corticosteroids with a favorable outcome, but which becomes aggravated by the occurrence of necrotic skin lesions at the cessation of corticosteroid therapy on the patient s own initiative. After the resumption of the corticosteroid therapy, the lesions and symptoms improve. To our knowledge, this case report is the first one that describes an association of two major conditions, extrinsic allergic alveolitis and cutaneous leukocytoclastic angiitis, in the same clinical context of an occupational exposure to specific pollutants. Long-term corticosteroid therapy has proved to be useful in preventing relapses and improving the patient s clinical status with the association of cutaneous leukocytoclastic angiitis and extrinsic allergic alveolitis. Considering our findings in this case report, we may suggest the inclusion of systemic vasculitis on the list of recognized professional diseases.

Corresponding author: Nina Ionovici, Associate Professor, MD, PhD; e-mail: ninaionovici@yahoo.com; Florina Nechita, Lecturer, PhD; e-mail: florina.nechita@yahoo.com

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41. Remember the Romanian pioneers: Alexandru Obregia (1860-1937) - first in vivo suboccipital puncture

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

In a time when doctors had limited knowledge about neuroanatomy and were focused primarily on clinical data, paraclinical investigations were overlooked even though they offered much needed information about the patients. Prof. Dr. Alexandru Obregia (1860-1937) is one of the forgotten pioneers of cerebrospinal fluid (CSF) investigation techniques. He envisioned, performed, and wrote about the very first in vivo suboccipital puncture, in 1908. The invention of this investigation technique was a considerable step forward in understanding the CSF and was Prof. Alexandru Obregia s most important scientific work. This, in turn, inspired Thoma Ionescu (1860-1926) to create the general rachianesthesia technique, in 1919, which allowed surgeons to perform a new range of procedures safely. The universal medical literature bears witness that this procedure was performed in other countries only after five years by Antonio et Bramman and after 11 years by Wegeforth, Ayer et Errik, thus confirming without a doubt Prof. Alexandru Obregia s priority in this historical finding.

Corresponding author: Aurel George Mohan, Associate Professor, MD, PhD; e-mail: mohanaurel@yahoo.com

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42. Letter to the Editor: Vascular foam cell dots in thyroid angioma-like lesions: fine needle aspiration or contrast substance-related lesions?

Adriana Handra-Luca, Habib Mohamed Ben Romdhane

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Corresponding author: Adriana Handra-Luca, MD, PhD; e-mails: adriana.handra-luca@aphp.fr, adriana.handra-luca@hotmail.com, adriana.handra-luca@univ-paris13.fr

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43. Book Review: Adela Cristina Lazar. Bisphosphonate therapy in dental medicine. A guide for dentists

Mariana Pacurar

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Corresponding author: -

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