ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 61 No. 3, July-September 2020

1. Hepatic stellate cells - from past till present: morphology, human markers, human cell lines, behavior in normal and liver pathology

Rada-Teodora Sufletel, Carmen Stanca Melincovici, Bogdan-Alexandru Gheban, Zaharie Toader, Carmen Mihaela Mihu

Hepatic stellate cell (HSC), initially analyzed by von Kupffer, in 1876, revealed to be an extraordinary mesenchymal cell, essential for both hepatocellular function and lesions, being the hallmark of hepatic fibrogenesis and carcinogenesis. Apart from their implications in hepatic injury, HSCs play a vital role in liver development and regeneration, xenobiotic response, intermediate metabolism, and regulation of immune response. In this review, we discuss the current state of knowledge regarding HSCs morphology, human HSCs markers and human HSC cell lines. We also summarize the latest findings concerning their roles in normal and liver pathology, focusing on their impact in fibrogenesis, chronic viral hepatitis and liver tumors.

Corresponding author: Carmen Stanca Melincovici, Lecturer, MD, PhD; e-mail: cmelincovici@yahoo.com

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2. Global hepatitis C elimination: history, evolution, revolutionary changes and barriers to overcome

Carmen Nicoleta Oancea, Anca Elena Butaru, Costin Teodor Streba, Daniel Pirici, Ion Rogoveanu, Mihai Mircea Diculescu, Dan Ionut Gheonea

The fundamental discovery of the hepatitis C virus (HCV) in 1989 has led to winning this year s Nobel Prize in Medicine. This achievement guided all the steps in identifying the elements of the virus, in order to develop the treatment and to increase the screening solutions, which have slowed the exposure to the virus. The management of infection started with interferon-alpha (IFN-alpha), which has later enhanced by adding Ribavirin. Nowadays, HCV treatment is based on direct-acting antiviral agents (DAAs). Currently, HCV infection benefits of curative treatment, with which most patients can be cured. When speaking about hepatitis C future, we can say it is looking bright, considering all the progress that has been made in recent years and all the options that we have for curing all genotypes of HCV infection. The aim of this review is to sum up the historical characteristics of HCV discovery, the evolution of treatment and screening actions, gaps, and stages for achieving the international elimination target of the World Health Organization.

Corresponding author: Costin Teodor Streba, Associate Professor, MD, PhD; e-mail: costin.streba@umfcv.ro

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3. Current classification systems and standardized terminology in cytopathology

Tibor Mezei

The history of classification systems and the search for a unified nomenclature in cytopathology spans several decades and expresses the preoccupation of all those involved to make cytopathology a reliable diagnostic tool and a trusted screening method. Early classification schemes, applicable to exfoliative and aspiration cytology, attempted to set some basic standards for how non-gynecological cytopathology findings should be reported. While useful in establishing some basic guidelines, these were not specific to the various fields of non-gynecologic cytopathology, often burdened with specific problems. Cytopathology has evolved tremendously in the last couple of decades, undoubtedly boosted by the emergence of various classification schemes that, more than ever, are based on evidence gathered by professionals across the globe. The benefit of classification systems and standardized nomenclature in cytopathology is to provide useful, clear, and clinically relevant information for clinicians and ultimately to provide the best patient care. Standardized reporting systems make cytopathology reports more meaningful and robust. It now became standard that these include by default elements, such as adequacy criteria, diagnostic groups, risk of malignancy (ROM), and recommendations for patient management. In this brief review, we attempted to summarize how these classification schemes emerged and how they are reshaping the landscape of diagnostic cytopathology.

Corresponding author: Tibor Mezei, Lecturer, MD, PhD; e-mail: tmezei@pathologia.ro

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4. The role of mediating factors involved in angiogenesis during implantation

Lidia Boldeanu, Anda Lorena Dijmarescu, Mirela Radu, Cristian Adrian Silosi, Mircea Vasile Popescu-Driga, Ioan Sabin Poenariu, Isabela Silosi, Mihail Virgil Boldeanu, Marius Bogdan Novac, Liliana Victoria Novac

Angiogenesis is a critical component of normal implantation and placentation and underlines the importance of vascularization in early pregnancy. Differentiated expression of angiogenesis factors in different decision tissues during different stages of implantation, indicates their involvement in the regulation of vascular remodeling and angiogenesis. Disorders in vascular development may play a role in the pathogenesis of recurrent abortions. The success of implantation, placentation and subsequent pregnancy evolution requires coordination of vascular development and adaptations at both sides of the maternal-fetal interface. The human implantation process is a continuous process, which begins with the apposition and attachment of the blastocyst to the apical surface of the luminal endometrial epithelium and continues throughout the first trimester of pregnancy until the extravillous trophoblast invades and remodels maternal vascularization. Numerous regulatory molecules play functional roles in many processes, including preparation of the endometrial stroma (decidualization), epithelium for implantation, control of trophoblastic adhesion and invasion. These regulatory molecules include cytokines, chemokines, and proteases, many of which are expressed by different cell types, having slightly different functions as the implant progresses.

Corresponding author: Mihail Virgil Boldeanu, Lecturer, MD, PhD; e-mails: boldeanumihailvirgil@yahoo.com, mihail.boldeanu@umfcv.ro; Marius Bogdan Novac, Lecturer, MD, PhD; e-mail: mariusnovac2005@yahoo.com

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5. Congenital systemic candidiasis: a comprehensive literature review and meta-analysis of 44 cases

Tiberiu Augustin Georgescu, Antonia-Carmen Lisievici, Octavian Munteanu, Florentina Ligia Furtunescu, Ovidiu Gabriel Bratu, Costin Berceanu, Roxana Elena Bohiltea

Systemic candidiasis is a frequent complication in neonatal units, but congenital systemic candidiasis is an unusual diagnosis, observed in both full-term and preterm infants, with less than 50 cases reported to date. Congenital candidiasis presents with a wide spectrum of symptoms, ranging from diffuse skin eruptions to severe systemic disease, resulting in fetal demise or early neonatal death. Although management guidelines have been published almost two decades ago, due to the rarity of this type of infection, conclusive recommendations are difficult to establish, since they are based on anecdotal experience. In this paper, we present a comprehensive meta-analysis of the current scientific knowledge regarding congenital candidiasis, which spans 54 years and includes a total of 44 cases.

Corresponding author: Octavian Munteanu, Assistant Lecturer, MD, PhD; e-mail: octav_munteanu@yahoo.com; Florentina Ligia Furtunescu, Associate Professor, MD, PhD; e-mail: florentina.furtunescu@umf.ro

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6. Medullary thyroid cancer: molecular factors, management and treatment

Efstathios Pavlidis, Konstantinos Sapalidis, Fotios Chatzinikolaou, Isaak Kesisoglou

Medullary thyroid cancer (MTC) is an infrequent neuroendocrine tumor, which amounts to 3-5% of all thyroid malignancies. Approximately 75-80% of MTCs are sporadic neoplasms. The rest of 20-25% are familial cases that belong to multiple endocrine neoplasia (MEN) syndromes, specifically MEN2 and MEN3. These cases of familial MTC are attributed to an activating germline mutation of a tyrosine kinase receptor gene, the rearranged during transfection (RET) proto-oncogene, located on chromosome 10q11.21. These mutations are also found in some cases of sporadic MTC. This review sets forth in summary the accepted guidelines and approaches regarding diagnosis, management, and treatment of MTC. Surgical resection is the standard care, and an early, prophylactic intervention is performed in genetic cases. Further investigation and understanding of the molecular pathways involved in the growth and advancement of MTC is required in order to provide efficient therapy in cases of progressive disease.

Corresponding author: Efstathios Pavlidis, Assistant Professor of Surgery, MD, PhD, MSc; e-mail: pavlidis.md@gmail.com

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7. Morphological, genetic and clinical correlations in infantile hemangiomas and their mimics

Alina Costina Luca, Ingrith Crenguta Miron, Laura Mihaela Trandafir, Elena Cojocaru, Ioana Alexandra Paduret, Mioara Florentina Trandafirescu, Alin Constantin Iordache, Elena Tarca

Infantile hemangiomas (IHs) are the most frequent pediatric benign vascular tumors, with a reported incidence of 5% to 10%. They have self-limiting evolution pattern divided into a growth phase in the first 12 months and a regression one, that may take up to 10 years. Occasionally, hemangiomas might lead to local or systemic complications, depending on their morphological characteristics. The first line of treatment is beta-blockers, such as Propranolol, Timolol, Nadolol, administered either locally or systemically. Newer therapeutic strategies involving laser therapy and angiotensin-converting enzyme inhibitors are being studied, while older treatment modalities like corticosteroids, Imiquimod, Vincristine, Bleomycin and Interferon-alpha have become second line therapy options. Before establishing the appropriate treatment, clinical, histological, and imaging investigations are required.

Corresponding author: Elena Cojocaru, Associate Professor, MD, PhD; e-mail: ellacojocaru@yahoo.com; Laura Mihaela Trandafir, Associate Professor, MD, PhD; e-mail: trandafirlaura@yahoo.com

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8. Different patterns of p16INK4a immunohistochemical expression and their biological implications in laryngeal squamous cell carcinoma

Camelia-Sidonia Lazar, Alina Simona Sovrea, Carmen Georgiu, Doinita Crisan, Stefan-Claudiu Mirescu, Marcel Cosgarea

Introduction: p16INK4a immunohistochemistry (IHC) is widely used to facilitate the diagnosis of human papillomavirus (HPV)-associated neoplasia, when >=70% of cells show strong nuclear and cytoplasmic positivity. In this study, we aim to compare partial expression patterns that do not fulfill the above criteria and seek biological implications in laryngeal squamous cell carcinoma (LSCC). Materials and Methods: p16INK4a IHC staining was conducted on representative sections of archived tissue from 88 LSCCs. Immunoreactivity was described based on four parameters: intracellular localization of immunostaining, intensity of immunostaining, distribution pattern and percentage of positive cells. Results: Six patterns of p16INK4a immunoexpression were observed and defined as: strong diffuse (strong immunostaining, expression in cytoplasm and nucleus in >70% of tumor cells), weak diffuse (moderate or weak immunostaining, expression in cytoplasm in >70% of tumor cells), marginal (strong cytoplasmic immunostaining, limited to the periphery of tumor islets), strong scattered (strong immunostaining, expression in cytoplasm and nucleus in <50% of tumor cells), weak scattered (moderate or weak immunostaining, expression in cytoplasm in <50% of tumor cells), negative (no expression). The pN stage of the patients was associated with p16INK4a immunoexpression patterns, the marginal pattern was only found in the pN0-Nx stages, while the weak diffuse pattern was more frequently observed in pN2-N3 stages. Conclusions: Partial immunostaining with architecturally distinct p16INK4a immunoexpression patterns may prove significant in stratifying characteristic clinicopathological subgroups among LSCC. Our observations may support the hypothesis that p16INK4a has different roles in different subcellular locations, with tumorigenic molecular pathways unrelated to HPV infection.

Corresponding author: Alina Simona Sovrea, Associate Professor, MD, PhD; e-mail: a_sovrea@yahoo.com

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9. Adjuvant effects of chemotherapeutics and Metformin on MFE-319 endometrial carcinoma cell line

Isil Aydemir, Elgin Turkoz Uluer, Oya Korkmaz, Mehmet Ibrahim Tuglu, Sevinc Inan

We aimed to investigate the cytotoxicity of Metformin, Cisplatin, and Paclitaxel on MFE-319 endometrial carcinoma cell line using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and immunocytochemistry assays. Half maximal inhibitory concentration (IC50) doses of three drugs alone and in the dual combinations were applied to the cells. Immunocytochemical method was performed for the cell survival and for phosphatidylinositol 3-kinase (PI3K), phosphorylated extracellular regulated kinases (pErk)-1/2, Akt-1, phosphorylated Akt (pAkt)-1/2/3 cell growth markers and angiogenic vascular endothelial growth factor (VEGF). Immunoreactivities were evaluated using H-score and analyzed using the one-way analysis of variance (ANOVA) test for statistics. It was found that these drugs caused a decrease in the immunoreactivities of these markers. Particularly, dual combination of Paclitaxel and Cisplatin decreased the immunoreactivities of PI3K, pErk-1/2, Akt-1, and pAkt-1/2/3. Cisplatin and Paclitaxel were more effective than Metformin; on the other hand, Metformin has been shown to enhance the efficacy of these two drugs. In vitro or in vivo further studies are needed to investigate the efficacy of these three drugs via PI3K/Akt signal pathway.

Corresponding author: Isil Aydemir, Assistant Professor, MD, PhD; e-mail: isil_aydemir@yahoo.com

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10. Assessment of mismatch repair deficiency, CDX2, beta-catenin and E-cadherin expression in colon cancer: molecular characteristics and impact on prognosis and survival - an immunohistochemical study

Carmen Stanca Melincovici, Adina Bianca Bosca, Sergiu Susman, Ancuta Cutas, Mariana Marginean, Aranka Ilea, Ioana Maria Moldovan, Elena Mihaela Jianu, Maria Adriana Neag, Adriana-Elena Bulboaca, Carmen Mihaela Mihu

Microsatellite instability (MSI) or the deficiency of mismatch repair (MMR) proteins is one of the molecular pathways of colorectal tumorigenesis and may have important clinical implications in predicting the treatment response. We evaluated the relationship between clinicopathological features and MMR proteins [mutL homologue 1 (MLH1), mutS homologue 2 (MSH2), mutS homologue 6 (MSH6), postmeiotic segregation increased 2 (PMS2)], adhesion molecules (E-cadherin, beta-catenin) and caudal-type homeobox 2 (CDX2) in 31 patients with colon adenocarcinoma, using immunohistochemistry. We also aimed to assess the prognostic value of the studied proteins. MLH1 loss was correlated to PMS2 loss (p=0.006) and MSH2 loss (p=0.023); MSH2 loss was significantly associated to MSH6 loss (p=0.011). Tumors with MSH6 loss, together with tumors with PMS2 loss, covered all the patients with MSI status. We found a significant correlation between MSI tumors and mucinous histological type (p=0.03), but no significant associations with other clinicopathological features or with survival rate. There was a significant correlation between E-cadherin expression and differentiation degree (p=0.018) and between beta-catenin expression and lymph node invasion (p=0.046). No significant association between CDX2 loss and any clinical or pathological features was found (p>0.05). No significant differences were identified in overall survival according to E-cadherin, beta-catenin or CDX2 expression (p>0.05). In our study, PMS2 loss was significantly correlated with CDX2 loss (p=0.03). In conclusion, the molecular analysis of biological markers for colon cancer may be important for patient stratification, in order to select the optimal treatment algorithm. Our results suggest that probably the double panel (MSH6 and PMS2) is enough to detect the MSI status, instead of using the quadruple panel.

Corresponding author: Adina Bianca Bosca, Associate Professor, MD, PhD; e-mail: biancabosca@yahoo.com

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11. Experimental model for the study of traumatic brain injury

Ilie Dumitru, Marian Valentin Zorila, Razvan Stefan Tolescu, Laurentiu Racila, Cristina Ileana Pascu, Alexandru Constantin Oprica, Daniela Vasilica Burghila, Lucian Matei, Elena Janina Vilcea, Cristina Popescu, Oana Badea-Voiculescu, Laurentiu Mogoanta

Traumatic brain injury (TBI) represents a public healthcare problem and a major economic burden, all over the world. It is estimated that every year, on the globe, there occur about two million severe TBI and over 42 million mild TBI. The main causes of TBI in civil population are fallings, followed by car accidents. In the last decades, the accelerated development of car industry and the poor development of traffic infrastructure in low- and average-income countries led to an increasing number of brain injuries, this becoming a major problem for medical health systems. According to some studies, approximately 1.35 million people die every year because of car accidents. In the last four decades, these types of injuries started to be studied in order to understand the lesion mechanisms for developing new safety equipment that may be installed on vehicles. The device presented by us for causing a TBI in a lab rat (mechanical pendulum) allows the performance of several major types of TBI, according to the kinetic energy, exposure area, contact surface, etc. The impact energies obtained by the device we presented may vary on a large scale, from less than 1 J up to 10 J, according to its weight, launching angle and impact head shape, thus being obtained minor, moderate or severe TBI.

Corresponding author: Marian Valentin Zorila, Assistant, MD, PhD; e-mail: zorilavaly@yahoo.com.au

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12. Insights into molecular pathways of endometriosis and endometriosis-related ovarian carcinoma

Ioana Pavaleanu, Ludmila Lozneanu, Raluca Anca Balan, Simona Eliza Giusca, Elena-Roxana Avadanei, Irina-Draga Caruntu, Cornelia Amalinei

Background: Endometriosis is a benign estrogen-dependent gynecological disease involving components of the female genital tract (uterus, Fallopian tubes, ovaries, large, round, and utero-sacral ligaments) and intra- and extraperitoneal regions. Since the moment of its etiopathogeny has been identified, the intrinsic capacity of endometriosis malignant transformation has been hypothesized. Patients, Materials and Methods: Our study included a total number of 50 patients diagnosed with endometriosis (31 cases) and endometriosis-related ovarian carcinoma (EOC) (19 cases). A clinicopathological and immunohistochemical study directed towards the detection of atypical transition lesions and the similitudes in epithelial-mesenchymal transition (EMT) phenomenon [E-cadherin/beta-catenin/cytokeratin 18 (CK18)], apoptosis [B-cell lymphoma 2 (Bcl-2)/Bcl-2-associated X (Bax)], and hormonal dynamics mirrored by the immunoexpression of estrogen receptor (ER) and progesterone receptor (PR) in endometriosis and EOC glands and stroma has been performed. Results: Our study showed a higher immunoexpression of CK18 and E-cadherin in endometriosis than in neoplastic counterparts, while beta-catenin had a stronger immunoexpression in tumors compared with endometriotic areas, with statistically significant differences between the studied groups. Bcl-2/Bax higher rate in endometriosis had a statistically significant association to a more aggressive tumor behavior (p=0.020). ER immunoexpression was stronger in endometriosis, with less negative scores compared to EOC, while PR immunoexpression was stronger in endometriosis, with a lower percent of negative scores compared to EOC. PR immunostaining was correlated to ovarian location of endometriosis (p=0.004) and tumor grade of EOC (p=0.027). Stromal ER and PR immunoexpression has been significantly lower in endometriosis in comparison to tumor stroma (p=0.001) and PR stromal immunoexpression had been higher in more differentiated tumors compared to less differentiated types (p=0.005). Conclusions: Our study supports that endometriosis is a precursor of EOC by the identification and the coexistence of both lesions in the investigated cases, the identification of intermediate lesions, as well as the expression of EMT immunomarkers, along with apoptosis and steroid receptors immunoexpression.

Corresponding author: Ludmila Lozneanu, Lecturer, MD, PhD; e-mail: ludmila.lozneanu@umfiasi.ro; Raluca Anca Balan, Associate Professor, MD, PhD; e-mail: raluca.balan@umfiasi.ro

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13. Prostate carcinomas mimicking a digestive malignancy

Sorin Dema, Alis Liliana Carmen Dema, Sorina Taban, Bianca Roxana Nataras, Livius Cosmin Daminescu, Ciprian Constantin Duta, Alin-Adrian Cumpanas, Tiberiu Razvan Bardan

Aim: To report our experience with specific cases of prostate cancer (PC) in which patients presented digestive symptoms, cases that represent a challenge and a source of error regarding the clinical and morphological diagnosis. Methods: The most important clinical and pathological data were collected from three patients with PC which presented symptoms and/or investigations that initially suggested a digestive malignant tumor. Results: We identified three patients with PC where the prostate tumor was not suspected based on the clinical-imagistic data, the correct diagnosis being the prerogative of the morphological investigation: in the first case, PC was detected during the microscopic examination of the lymph nodes (LN) in the intestinal resection specimen performed for suspected rectal cancer (RC), in the second case, in which the PC was synchronous with a RC, the dominant symptomatology was gastrointestinal, and in the third case, initially, the patient presented a widely disseminated PC, with pleural and bone metastases, as well as LN metastases, and apparent peritoneal involvement. Conclusions: Unusual forms of PC presentation are not as rare as expected and should be acknowledged by all those involved in diagnosing this neoplasm. PC should always be considered in the differential diagnosis of a rectal tumor. The immunohistochemical (IHC) investigation is essential for establishing the diagnosis in difficult cases. An integrated approach of the interpretation of clinical manifestations, imagistic and serological changes would shorten the diagnostic time and help reduce diagnostic errors.

Corresponding author: Alis Liliana Carmen Dema, Professor, MD, PhD; e-mail: dema.alis@umft.ro

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14. Value of endoscopy with narrow-band imaging and probe-based confocal laser endomicroscopy in the diagnosis of preneoplastic lesions of gastrointestinal tract

Petrica Popa, Costin Teodor Streba, Mihaela Calita, Vlad Florin Iovanescu, Dan Nicolae Florescu, Bogdan Silviu Ungureanu, Andreea Doriana Stanculescu, Raluca Niculina Ciurea, Carmen Nicoleta Oancea, Daniel Georgescu, Dan Ionut Gheonea

Introduction: Amongst all malignant tumors, cancers of the digestive tract rank first in terms of yearly deaths. Patients above 60 years of age are the most affected, as the diagnosis is frequently made in advanced stages of the disease when therapy is less effective. Our study aimed to evaluate the efficiency of narrow-band imaging (NBI) endoscopy and probe-based confocal laser endomicroscopy (pCLE) in the correct diagnosis of preneoplastic lesions in the upper and lower digestive tract. Patients, Materials and Methods: We included 46 patients with digestive preneoplastic lesions, who underwent either upper or lower digestive endoscopy, followed by NBI and pCLE. We recorded 5-10 frames per each lesion, from different angles and distances during white-light endoscopy and selected frames from full recordings of NBI and pCLE. Usual preparation was used for the endoscopic procedures; pCLE required in vivo administration of 10% Sodium Fluorescein as a contrast agent. Pathology was performed in case of solid tumors. Three medical professionals with different levels of training, blinded to the results, interpreted the data. Results: The experienced physician correlated very well the NBI findings with pathology (0.93, p=0.05), while the resident physician and the experienced nurse obtain lower, albeit still statistically significant, values (0.73 and 0.62, respectively). For pCLE, the experienced physician obtained near-perfect correlation with pathology (0.96), followed closely by the resident physician (0.93). The nurse obtained a modest correlation (0.42). All examiners obtained approximately equal performances in discerning between malignant and benign lesions. Conclusions: Digestive endoscopy in NBI mode proved its effectiveness. Even less experienced endoscopists can achieve good results, while an experienced nurse can positively influence the diagnosis. In the case of pCLE, when available, it can greatly reduce diagnostic times, while requiring higher expertise and specialty training.

Corresponding author: Costin Teodor Streba, Associate Professor, MD, PhD; e-mail: costin.streba@umfcv.ro

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15. The immunophenotype of epithelial to mesenchymal transition inducing transcription factors in salivary gland adenoid cystic carcinomas

Iulia Cristiana Belulescu, Claudiu Margaritescu, Cristiana Iulia Dumitrescu, Maria Cristina Munteanu, Luminita Daguci, Otilia Clara Margaritescu, Marius Matei

Adenoid cystic carcinoma (ACC) is the second most common malignant salivary glands neoplasms with a controversial biological behavior. Even though these tumors grow slowly, they have increased potential for recurrence and distant metastasis. In order to elucidate this behavior, our study aimed to investigate the immunoexpression in such tumors of the most important transcriptional factors [Twist, Snail, Slug, and zinc finger E-box binding homeobox 1 (ZEB1)] involved in the epithelial-mesenchymal transition process. The highest level of expression was recorded for Twist, present in all the investigated cases, followed by the Slug and Snail, while no tumor parenchyma reactivity was noticed for the ZEB1 factor. There were tumor reactivity differences regarding topography, histopathological variant, and nerve and lymph node invasion status. Thus, tumors developed from the intraoral minor salivary glands, with solid pattern, perineural invasion, locally aggressive and with lymph node metastasis were the most reactive. Therefore, these transcription factors could be useful as prognostic biomarkers and efficient therapeutic targets in such salivary malignancies.

Corresponding author: Claudiu Margaritescu, Professor, MD, PhD; e-mail: c_margaritescu2000@yahoo.com; Maria Cristina Munteanu, Lecturer, MD, PhD; e-mail: cristina_omf@yahoo.com

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16. Direct and imaging morphometry for the localization of the mandibular foramen (MF) in dentate and edentulous human subjects

Ovidiu Romulus Gherghita, Vanda Roxana Nimigean, Irma Eva Csiki, Violetta Baran-Poesina, Maria Justina Roxana Virlan, Victor Nimigean

The area of choice where anesthesia of this nerve is performed. The position of the MF can vary, and accurately establishing its location and topographic variations is of great importance for the successful anesthesia of the inferior alveolar nerve. Materials and Methods: We carried out two morphometric ex vivo studies concerning the topography of the MF, on dry human mandibles coming from dentate and completely edentulous human subjects of known age and gender and an in vivo morphometric study, through cone-beam computed tomography (CBCT) scans, concerning the topography of the MF in human subjects having Kennedy Class I mandibular edentulism. The morphological characteristics we investigated were: the distance between the MF and the anterior margin of the mandibular ramus (MF-AM distance), the distance between the MF and the posterior margin of the mandibular ramus (MF-PM distance), the distance between the MF and the inferior margin of the mandibular ramus (MF-IM distance), the distance between the MF and the temporal crest of the mandibular ramus (MF-TC distance), the distance between the MF and the superior margin of the mandibular ramus (MF-SM distance), and the vertical and transverse diameters of the MF. The results were statistically processed in Stata/MP13 software package using Student s t-test and two-way analysis of variance (ANOVA). Results: Through direct morphometry on dentate dry human mandibles, the MF-AM and the MF-SM distances showed statistically significant differences for age, gender and for interactions, while the MF-PM and MF-IM distances showed statistically significant differences for age and for interactions. In the case of the MF-TC distance, the only significant difference observed was for the gender. No statistical significance was found for side, age, gender, and interactions in the cases of MF vertical and transverse diameters. Through direct morphometry on completely edentulous dry human mandibles, the MF-PM and MF-SM distances showed statistically significant differences for age, gender and for interactions, while the MF-AM, MF-IM, and MF-TC distances, as well as the MF vertical and transverse diameters showed statistically significant differences for age and for model (interactions). The results showed that MF is 2 mm closer to the anterior margin of the mandibular ramus after having lost teeth. Through imaging morphometry, the MF-PM distance and the vertical diameter of MF showed statistically significant differences for age, gender and for interactions, while the MF-AM, MF-IM, MF-SM and MF-TC distances, as well as the transverse diameter of MF showed statistically significant differences for age and for interactions. Comparing the results obtained by the three studies, we found no statistically significant differences in relation to the gender of the subjects. The MF-IM and MF-TC distances and the transverse diameter of MF showed statistically significant differences for age, study and for interactions, while the MF-AM, MF-PM and MF-SM distances, as well as MF vertical diameter showed statistically significant differences only for age and for interactions. Morphological symmetry was demonstrated through our three studies, no statistically significant differences being determined in relation to side. Conclusions: The results of this research should increase the level of awareness among dentists with respect to MF topography changes with loss of teeth and help dental practitioners in refining the inferior alveolar nerve block techniques.

Corresponding author: Vanda Roxana Nimigean, Associate Professor, DMD, PhD; e-mail: vandanimigean@yahoo.com

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17. Osteopontin and osteoprotegerin in atherosclerotic plaque - are they significant markers of plaque vulnerability?

Cristina Strobescu-Ciobanu, Simona Eliza Giusca, Irina-Draga Caruntu, Cornelia Amalinei, Andreea Rusu, Elena Cojocaru, Radu Florin Popa, Cristian Dumitru Lupascu

Atherosclerosis (ATS) is still considered as a major, global health problem. For a deeper understanding of its pathogenesis, in the last years the research was translated from tissue visible events to molecular mechanisms. Osteopontin (OPN) and osteoprotegerin (OPG) are two molecules that have been associated with the initiation and progression of ATS lesions. The aim of our study was to assess the OPN and OPG expression in advanced stages of carotid ATS, to analyze the correlation between these markers and the ultrasonographic plaque properties, pointing out the identification of possible patterns that can predict plaque vulnerability and risks of restenosis. The study group comprised 49 consecutive patients (38 males and 11 females) diagnosed with carotid stenotic lesions by using ultrasonography. The carotid endarterectomy specimens were standardly processed for histopathological and immunohistochemical exams. The OPN and OPG expression was semi-quantitatively assessed. Our results sustained the relationship between histological American Heart Association (AHA) type and ultrasonographic classification (echogenic versus echolucent) (p<0.001). The semi-quantitative analysis showed that in most cases (31 plaques) OPG and OPN had opposite expressions, whereas in the remaining cases (18 plaques) the expression was similar. There were no correlations between low versus high expression of intra-plaque OPN and OPG (p=0.335). We found significant correlation for OPN and plaque echogenicity (p=0.011), but not for OPG (p=0.079). OPN expression (low versus high) was correlated with plaque type (stable versus unstable) (p=0.036), plaque ulceration (p=0.009) and inflammation (p<0.001). OPG expression (low versus high) did not reveal statistically significant differences with plaque type (stable versus unstable) and vulnerability plaque parameters, respectively. OPG and OPN co-exist in carotid atherosclerotic plaque demonstrating a modulatory role in inflammatory and calcification processes. OPG is strongly expressed in stable, calcified plaques, while OPN is poorly expressed in calcified plaques and in plaques without hemorrhage, ulceration, inflammation, or necrosis. Starting from the molecular mechanisms, further studies of biomarkers are important to identify new therapeutic resources meant to prevent and treat vascular calcification.

Corresponding author: Radu Florin Popa, Associate Professor, MD, PhD; e-mail: radu.popa@umfiasi.ro

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18. The role of androgen receptors in vascular and cell proliferation of the prostate adenocarcinomas

Andrei Panus, Claudiu Margaritescu, Petru Octavian Dragoescu, Paul Ioan Tomescu, Mihai Lucian Stefanescu, Alex Emilian Stepan

Prostate adenocarcinoma (PA) is by incidence and prognosis a unique model for investigating the biomolecular mechanisms involved in tumor progression. In this study, we analyzed the immunoexpression of androgen receptor (AR), cluster of differentiation 105 (CD105) and Ki67 for 61 cases of PA, in relation to the main clinicopathological parameters of the lesions. The AR scores, CD105 microvessel density (MVD) and Ki67 proliferation index (PI) were significantly higher in patients with serum prostate-specific antigen (PSA) above 20 ng/mL, in ductal, colloid and sarcomatoid types of PA, in growth patterns 4-5 or mixed, respectively in the case of high-grade advanced stage tumors, with perineural and vascular invasion, as well as in groups with a reserved prognosis. The results obtained, reflected in the positive linear correlation of AR, CD105 and Ki67 expression, indicate synchronous endocrine, angiogenic and proliferative mechanisms involved in tumor progression, which can be used to optimize the targeted tumor therapy.

Corresponding author: Paul Ioan Tomescu, Associate Professor, MD, PhD; e-mail: paul.tomescu@yahoo.com; Petru Octavian Dragoescu, Lecturer, MD, PhD; e-mail: pdragoescu@yahoo.com

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19. The role of neuronal apoptosis in Valproic Acid brain-related teratogenesis: a histochemical and immunohistochemical study in BALB/c mice

Maria Eleni Manthou, Soultana Meditskou, Chrystodoulos Lykartsis, Konstantinos Sapalidis, Konstantina Sorkou, Elpida-Niki Emmanouil-Nikoloussi

Objectives: The purpose of this study was to examine the teratogenic effects of Valproic Acid (VPA) and to investigate the role of apoptosis in neural tissue development. Although an apoptotic activity due to VPA has been reported, a direct connection of VPA-induced apoptosis with embryonic brain and/or spine malformations and teratogenesis has not yet been established. Materials and Methods: VPA was administered to BALB/c mice, from the 7th to the 10th gestational days. Macroscopical congenital anomalies were registered under a stereomicroscope and were further histologically studied. Immunohistochemistry was performed with terminal deoxynucleotidyl transferase (TdT)-mediated deoxyuridine triphosphate (dUTP) nick-end labeling (TUNEL) staining. Results: Birth defects were described and an increase of the apoptotic activity in the brain was immunohistochemically identified. Conclusions: Considering the increased and very intense TUNEL expression of the neural cells of treated animals fetuses, it is suggested that VPA triggers a pathological increase of apoptosis resulting in an imbalance between cell proliferation and cell death, the final result of which is malformation.

Corresponding author: Soultana Meditskou, Associate Professor, MD, PhD; e-mail: meditskou@gmail.com

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20. Analysis of the occurrence and distribution of primary and recurrent basal cell carcinoma of head and neck coupled to the assessment of tumor microenvironment and Sonic hedgehog signaling

Jelena Moisejenko-Golubovica, Oleg Volkov, Anna Ivanova, Valerija Groma

Often, basal cell carcinoma (BCC) displays local aggressiveness, and when developed in the head and neck presents with deep tissue invasion and recurrence. Previous studies have pointed out the necessity of systematic assessment of primary and recurrent BCC based on a better understanding of the biology and function of its microenvironment. Although hedgehog-dependent tumor cells signaling to the underlying stroma, and vice versa, have been demonstrated to be implicated in the pathogenesis of BCC, little is known about peculiarities of the tumor microenvironment and the above-mentioned signaling in the head and neck. The occurrence and distribution of 79 primary and recurrent BCCs developed in the head and neck region were estimated. The data were coupled with the immunohistochemical assessment of type IV collagen, laminin, alpha-smooth muscle actin (alpha-SMA), and Sonic hedgehog (Shh). The frequency of the mixed BCCs and the predominance of the nose and cheek region affection by primary and recurrent tumors were demonstrated. Furthermore, the increase of peritumoral and entire stromal alpha-SMA immunoreactivity in the mixed recurrent BCC was confirmed using statistics. We found the increase of strong levels of Shh immunoexpression in the aggressive variants of BCC - infiltrative, mixed, and micronodular. Surprisingly, we confirmed the upregulation of Shh paralleled by the downregulation of alpha-SMA immunoexpression in the superficial subtype of the tumor. Our results suggest the necessity of further studies assessing the nature of the tumor along with the peculiarities of signaling in BCCs of head and neck.

Corresponding author: Jelena Moisejenko-Golubovica, MD; e-mail: jelena.moisejenko@gmail.com

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21. Successful management of spontaneous bone regeneration after jaws cystectomy using PRGF approach; case series

Cristian Adrian Ratiu, Ioana Adela Ratiu, Simona Cavalu, Adina Bianca Bosca, Gabriela Ciavoi

In the jaws, the healing process of bone defects occurs differently compared with other anatomical sites where healing is done by the formation of scar tissue. This is due to physiological bone remodeling and continuous bone resorption and apposition. In the case of large cysts, there is an increased risk of postoperative infection due to the retraction of the blood clot on the bony walls. The use of plasma rich in growth factors (PRGF), with or without autologous bone addition, for filling the cystic cavities is beneficial not only for its antimicrobial effect, but also due to simultaneously release of growth factors from platelet alpha granules and adhesive proteins. The aim of our work was to emphasize the spontaneous bone healing of the maxilla and mandible after the enucleation of large and medium-sized cysts in asymptomatic patients of different age. The outcome of three patients who underwent surgery for removal of radicular cysts is presented. Imagistic [cone-beam computed tomography (CBCT)] and histological examination was performed aiming to evaluate the quality of new bone at the site of the bone defect, after different time intervals. By using PRGF approach, the healing of mandibular bone occurred 18 months after cystectomy in a smoker patient, 54-year-old, while the healing of maxillary bone using autologous bone mixed with PRGF occurred after six months in a 63-year-old patient. In a young patient (14 years old), the regeneration period was six months, using PRGF and a fibrin cloth for filling the defect.

Corresponding author: Adina Bianca Bosca, Associate Professor, DMD, PhD; e-mail: biancabosca@yahoo.com; Ioana Adela Ratiu, Lecturer, MD, PhD; e-mail: ratiu_ioana@yahoo.com

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22. Abdominal elastotic lesions. A clinicopathologic study of 23 cases

Jose-Fernando Val-Bernal, Marta Maria Mayorga, Francisco Javier Garcia-Gutierrez

Abdominal elastotic deposits are uncommon lesions that often presents as polyps. They show three histological patterns: fibroelastosis, angioelastosis, and elastofibroma. We describe 23 cases including rare locations, such as mesentery, greater omentum, hernia sac, spleen, peripancreatic fat, and hypodermal fat. The age of the patients ranged from 49 to 93 years (mean, 76.8 years). Most lesions were discovered incidentally in the microscopic study. The most frequent locations were peritoneal subserosa (43.5%) and mesentery/mesocolon/greater omentum (39.1%). The most common pattern was fibroelastosis (69.6%) followed by angioelastosis (26.1%). We observed one case of omental elastofibroma. A review of the 14 abdominal elastofibromas described including our case revealed that the age of the patients ranged from 45 to 88 years (mean, 68.5 years). Female predominance is striking (M:F, 1:12). The most common site was the stomach (50%). The greater omentum (14.3%), small intestine (7.1%), and pancreas (7.1%) are very rare sites for this lesion. Only one case before ours has been published in the greater omentum. The size of the lesions ranged from 0.7 cm to 8 cm (mean 3.2 cm). In 36.4% of the cases located in the digestive tract, the mucosa did not show alterations. Ulcerations (36.4%) or polypoid excrescences (18.2%) were mostly observed. Six (42.9%) cases were asymptomatic and six (42.9%) cases simulated a neoplasm. Two cases were associated with elastofibromas in other locations. Differential diagnosis includes amyloidoma, elastofibrolipoma, mesenteric elastic vascular sclerosis in neuroendocrine tumors, diverticular disease elastosis, pseudoxanthoma elasticum, pulse granuloma, and digestive lesions in patients treated with D-Penicillamine.

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

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23. Phenotypic heterogeneity of non-syndromic supernumerary teeth: genetic study

Stefan-Dimitrie Albu, Romina-Christiana Pavlovici, Marina Imre, George Ion, Ana Maria Cristina Tancu, Cristina-Crenguta Albu

Background: Numerical dental anomalies, through their phenotypic diversity and etiological complexity, represent a very topical chapter in dental practice. In Romania, there is no recent complex genetic study, regarding supernumerary teeth (ST), as a whole. Patients, Materials and Methods: In this research, through the specific genetic study of the phenotypic variability of ST, completed with clinical examinations and paraclinical investigations, to which statistical determinations were added, we performed a complex genetic-clinical and statistical analysis of ST, within a representative group, consisting of 574 patients, who came for specialized dental treatment, between 01/01/2018-05/30/2019, at the private dental offices (Lucky Dental), in Bucharest, Romania. Results: Following this study, it was possible to characterize the phenotypic variability of ST, to analyze the pattern of abnormality genetic transmission in the families of investigated patients, to identify people at risk, and specify the therapeutic conduct of choice, specific to each case. Conclusions: We consider this paper to be of interest for medical practice by bringing new, recent data on the current prevalence of non-syndromic ST, their clinical phenotypes, and the specifics of their genetic determinism in the studied population group.

Corresponding author: Cristina-Crenguta Albu, Associate Professor, MD, PhD; e-mail: crenguta.albu@yahoo.com; George Ion, Assistant Professor, DMD, PhD; e-mail: georgeiongxg@yahoo.com

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24. Therapeutic approach comparison in bicuspid aortic valve aortopathy and clinical practice implications

Ciprian Nicusor Dima, Caius Glad Streian, Marian Gaspar, Silviu Cristian Suciu, Constantin Caraion, Elian Octavian Boldu, Simona Cerbu, Emil Radu Iacob, Constantin Tudor Luca, Lucian Petrescu

Bicuspid aortic valve (BAV) is the most common heart valve malformation, and it may be associated with the development of long-term complications, such as aortic stenosis (AS) secondary to valvular calcification and aortic insufficiency (AI), with or without ascending aortic aneurysm (AAA). This study was performed at the Institute of Cardiovascular Diseases, Timisoara, Romania, from 2015 through 2018 and included a total of 105 patients with BAV. Out of the 105 BAV patients, 14 displayed AAA, alongside either AS or AI, and were selected undergo aortic valve replacement (AVR) alongside surgical replacement or aortoplasty of the ascending aorta, and the elastic fiber loss in the ascending aortic wall was evaluated for each patient. Two surgical interventions used alongside AVR in BAV patients with AAA and AS or AI were compared in this study: reduction ascending aortoplasty (RAA) and ascending aorta replacement (AAR). Postoperative follow-ups have shown RAA is useful short-term but that, in contrast to AAR, it leads to aortic redilatation over time. These results can contribute to a major future meta-analysis with the goal of improving the current clinical practice guidelines for BAV aortopathy.

Corresponding author: Emil Radu Iacob, Lecturer, MD, PhD; e-mails: radueiacob@umft.ro, radueiacob@yahoo.com; Simona Cerbu, Assistant, MD, PhD; e-mail: cerbusimona@yahoo.com

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25. Involvement of inflammatory cells in chronic rhinosinusitis with nasal polyps

Irina Enache, Elena Ionita, Florin Anghelina, Carmen Aurelia Mogoanta, Mircea Sorin Ciolofan, Alina Nicoleta Capitanescu, Alina Maria Vilcea, Alma Maria Florescu, Cristiana Eugenia Simionescu

Inflammation plays an important role in the pathogenesis of nasal polyps. Understanding the biomolecular action mechanisms of inflammatory elements can contribute to improving the prognosis of these lesions. The study analyzed the distribution and immunohistochemically quantified eosinophils [eosinophil major basic protein (BMK-13)], lymphocytes [cluster of differentiation (CD) 4, CD8, CD20] and plasmocytes (CD138) in both the epithelial and stromal compartment in relation to composite scores, which included specific histopathological parameters for 50 sinonasal polyps. Inflammatory elements predominated at stromal level, the high histological composite scores being frequently associated with increased expression of inflammatory elements. Also, the numerical distribution of inflammatory elements indicated positive linear relations within the groups BMK-13/CD8 and CD4/CD20/CD138, and a negative linear relation between the two groups. This aspect can support the existence of alternative or sequential pathogenic mechanisms involved in the pathogenesis of sinonasal polyps, and the results obtained can be used for a better stratification of patients in order to optimize the therapy.

Corresponding author: Carmen Aurelia Mogoanta, Lecturer, MD, PhD; e-mail: carmen_mogoanta@yahoo.com

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26. Hormone treatment and UVB exposure influences on female mice regarding skin physiological parameters, biochemical parameters and organ histology

Virgiliu Bogdan Sorop, Veronica Madalina Boruga, Iulia Andreea Pinzaru, Ileana Ramona Barac, Crinela Utescu, Anca Laura Maghiari, Flavia Baderca, Lavinia Balan, Maria Sorop-Florea, Victor Dumitrascu, Doru Mihai Anastasiu, Sebastian Simu, Daniela Radu, Oana Suciu

Females require at a certain period of life the administration or supplementation of specific hormones (estrogen, progesterone), for various needs, such as: prevention of unwanted pregnancies, decreased menstrual bleeding, dysmenorrhea and pelvic pain in endometriosis, alleviation of symptoms associated with menopause, regulation of certain skin processes related to acne or aging and others. Also, hormones could act as oncogenes being known eloquent examples of estrogens labeled both as promoters of cell specific alteration or as mutagenic agents. The use of hormones and exposure to solar radiation is expected to cause a number of adverse changes to the body, especially due to their association with malignant processes. The current study was purported as a basis for understanding certain processes that occur with the administration of hormones and exposure to ultraviolet B (UVB) radiation. The animal model was made on healthy adult female BALB/c mice, which were separated into groups and treated with Ethinylestradiol (EES), Levonorgestrel (LNG) and their combination in the presence of UVB radiation. Changes in skin physiological parameters were analyzed by non-invasive methods, biochemical parameters related to changes in blood circulating system were evaluated by standard methods and histopathological analysis was conducted to point out the changes at the level of the internal body. Measurement of skin parameters such as erythema, melanin, skin hydration, has highlighted some changes in hormone-treated and exposed to UVB radiation groups which were significant only in the case of erythema. Biochemical parameters showed variations in terms of liver enzymes in groups treated with active substances. Histologically, aspects of internal organs revealed significant changes in the group treated with EES and LNG and exposed to UVB radiation.

Corresponding author: Iulia Andreea Pinzaru, Associate Professor, PhD; e-mail: iuliapinzaru@umft.ro; Ileana Ramona Barac, Lecturer, MD, PhD; e-mail: ramona.barac@live.com

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27. Intradiploic epidermoid cysts - a series of three cases and our experience with literature data

Ovidiu Tica, Otilia Anca Tica, Elena Rosca, Monica Sabau, Ilarie Brihan, Carmen Anca Huniadi, Aurel George Mohan, Gabriela Mutiu, Mihaela Mirela Zdrinca, Camelia Liana Buhas, Larisa Renata Pantea-Rosan, Alina Cristiana Venter

Intracranial epidermoid cysts are rare, representing almost 1% of all primary tumors and when are located in the diploe result from entrapped ectodermal embryonic remnants. Because of frequent complications, imaging studies are mandatory for highlighting erosions of both outer and inner table of the calvaria and treatment preparation. We enlisted three female patients within our study, comparing imaging with histopathology aspects. Even though the bone destruction was evident, no atypia or malignant signs were highlighted in serial sections. The interesting fact that we present is that our patients are all females, opposed to what is written in literature. Although the positive diagnosis can be made by imaging, histopathological examination of these cysts is mandatory for identifying malignant behavior.

Corresponding author: Otilia Anca Tica, Assistant Professor, MD, PhD; e-mail: otilia_cristea01@yahoo.com

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28. Comparative clinicopathological aspects of chronic tonsillitis and adenoiditis in children

Stefanita Bianca Vintilescu, Elena Ionita, Alex Emilian Stepan, Cristiana Eugenia Simionescu, Marius Matei, Mioara Desdemona Stepan, Cristina Adriana Becheanu, Elena Carmen Niculescu

Chronic palatal and nasopharyngeal inflammations are common lesions in pediatric pathology, with major effects on children s development. The study included 34 cases of chronic tonsillitis and adenoiditis for which we quantified immunohistochemically and analyzed the distribution of inflammatory elements in the follicular, extrafollicular and epithelial compartments, in relation to the composite histological scores and the clinico-epidemiological profile of the lesions. The cases were more frequent under the age of 10, in female patients, coming from urban areas, with the diagnosis of tonsillitis. B-lymphocytes have been associated with follicular areas in tonsillitis and epithelial areas in adenoiditis. In all compartments, T-lymphocytes were more frequently associated with tonsillitis and plasma cells associated with adenoiditis. Macrophages and dendritic cells had a relatively uniform distribution for the three compartments in all cases. The results obtained indicate different inflammatory phenotypes for chronic tonsillitis and adenoiditis, an aspect that may be useful for stratifying patients for optimal therapy.

Corresponding author: Mioara Desdemona Stepan, Lecturer, MD, PhD; e-mail: dstepan80@yahoo.com; Marius Matei, Teaching Assistant, MD, PhD; e-mail: mariusmatei144@gmail.com

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29. Case report of a novel phenotype in 18q deletion syndrome

Roxana Elena Bohiltea, Monica Mihaela Cirstoiu, Florina Mihaela Nedelea, Natalia Turcan, Tiberiu Augustin Georgescu, Octavian Munteanu, Alexandru Baros, Anca-Maria Istrate-Ofiteru, Costin Berceanu

The latest decades are characterized by an enormous progression in the field of human genetics. In consequences, for various phenotypic manifestations, genetic testing could identify a specific underlying cause. An estimated incidence for all types of 18q deletions is one in 55 000 births predominant on females. About 94% of cases with 18q deletion syndrome appearance are de novo, and the remaining 6% are the inherited from a parent carrying a balanced chromosomal translocation. We present the case of a 35-year-old female who was admitted in our Unit for a second ultrasound opinion after being diagnosed at the second trimester scan at gestational age of 21 weeks of pregnancy with multiple brain and heart malformations, having the recommendation for fetal magnetic resonance imaging (MRI). Further investigations included genetic analysis and pathological examination. Major malformations diagnosed and confirmed were agenesis of the corpus callosum, ventriculomegaly with dilated fourth ventricle, partial agenesis of vermis, bilateral anophthalmia with wide nasal base and left cleft lip. Additional, cardiac malformation, with an important ventricular septal defect and overriding aorta were noted. The results of the microarray analysis showed an abnormal fetal karyotype with a loss of 30.5 basis identified in the long arm of chromosome 18. Although most of the cases of 18q deletion are sporadically or de novo, could be cases where the possible existing syndromes can be inherited from a healthy or mild affected parent. Therefore, in order to establish the recurrence risk, parental karyotypes are recommended.

Corresponding author: Octavian Munteanu, Assistant Professor, MD, PhD; e-mail: octav_munteanu@yahoo.com; Tiberiu Augustin Georgescu, Assistant Professor, MD, PhD; e-mail: tiberiuaugustin.georgescu@gmail.com

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30. Cystic schwannoma of the distal forearm. Case presentation

Valeriu Ardeleanu, Daniel Pirici, Anca Sava, Roxana Folescu, Andrei Gheorghe Marius Motoc

Schwannomas are well-encapsulated, benign tumors arising from Schwann cell constituting the nerve sheaths. We report a case of a cystic conventional schwannoma, measuring 2.5x3 cm, located in the distal forearm of a 33-year-old female patient with no sign of neurofibromatosis type 2 or type 3. The mass was painless, but Tinel s sign was positive. Ultrasonography showed a soft tissue cystic mass diagnosed as being synovial cyst in the left distal forearm. Surgical resection was performed without any complications. Histopathological examinations oriented the diagnosis to a schwannoma, but immunohistochemical stainings proved the tumor origin in Schwann cells and made the differential diagnosis with other pathologies, like neurofibroma, leiomyoma, epithelial cyst, synovial cyst, or ganglion cyst.

Corresponding author: Anca Sava, Professor, MD, PhD; e-mail: dr.anca.sava.68@gmail.com

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31. Proximal humerus chondrosarcoma in a young male patient

Razvan Ene, Florin Catalin Cirstoiu, Mihai Nica, Zsombor Alpar Panti, Corina Panaitescu, Elisa Popescu, Adrian Vasile Dumitru, Irina Anca Eremia, Adrian Cursaru, Dragos Ene

Proximal humerus chondrosarcoma is a rare localization of the common primary malignant cartilaginous tumor. Management is based on oncological surgical excision because of the inherent resistance to chemotherapy and radiation therapy. The most important prognostic factors with great impact on treatment strategy are histological grading and localization of the tumor. Proximal humerus chondrosarcoma carries a slightly better prognosis, especially for the low and moderate grade tumors. We present the case of a young patient with proximal humerus chondrosarcoma surgically managed in our Department, with the purpose of underlining the challenges posed by this localization for oncological excision and reconstruction but also the importance of histological grading for the treatment algorithm.

Corresponding author: Mihai Nica, MD; e-mail: mikx99n@gmail.com

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32. The riddle of the right ventricle

Ana-Maria Balahura, Andrada Camelia Guta, Valentin Enache, Cristian Balahura, Alexandra Emma Weiss, Cristina Japie, Elisabeta Badila, Daniela Bartos

Right ventricular (RV) myxoma is a very rare finding. Its differential diagnosis includes cardiac thrombus, and its risk of life-threatening complications mandates early diagnosis followed by surgical resection. We report the case of a patient with an incidental RV mass and a difficult differential diagnosis. A 66-year-old woman, first assessed in neurosurgery due to a lumbar herniated disc, was referred to cardiology for examination before proceeding to surgery. She complained of dyspnea on exertion present for the last few months and reported no fainting or syncope. Clinical examination showed intermittent pulmonary systolic murmur. Transthoracic echocardiography revealed an oval-shaped sessile mobile mass (42/18 mm) attached to the anterior RV wall. Computed tomography confirmed the presence of a RV mass with lower attenuation than the myocardium and extension towards the pulmonary trunk, without other abdominal or pulmonary masses that would suggest a thrombus. Cardiac magnetic resonance imaging described an ovoid mass (47/16 mm) in the right ventricle, clinging to the apical trabeculae, swinging during the cardiac cycle, causing partial obstruction of the pulmonary valve during systole. The patient underwent surgical resection of the tumor. Macroscopic specimen showed a translucent polypoid mass with hemorrhagic areas. Microscopy confirmed the diagnosis of RV myxoma. The case illustrates the difficulty of establishing the correct etiological diagnosis of a cardiac mass, especially when located in the right ventricle. Multimodality imaging remains the cornerstone of noninvasive tissue characterization of cardiac masses, still requiring histopathological confirmation, particularly in the setting of conflicting imaging results.

Corresponding author: Elisabeta Badila, Associate Professor, MD, PhD; e-mails: elisabeta.badila@gmail.com, elisabeta.badila@umfcd.ro

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33. Incidental case of primary renal lymphoma (PRL) in a patient with chronic hepatitis C infection. Report of a rare case

Mircea Litescu, Ion Daniel Baboi, Laura Paverman, Camelia Doina Vrabie, Niculae Iordache, Ionut Simion Coman, Corina-Veronica Lupascu-Ursulescu, Ion Dina, Valentin Titus Grigorean

Chronic viral hepatitis C (CHC) is a global health problem, being responsible for about 399 000 deaths worldwide, mostly from cirrhosis and hepatocellular carcinoma. Virus C infection has well known hepatic manifestations - cirrhosis and liver cancer - but the extrahepatic ones are responsible for up to 75% of morbidity in these patients. The well-known hepatitis C virus (HCV) lymphotropism is probably linked with the most frequent extrahepatic manifestations, mixed cryoglobulinemia and B-cell non-Hodgkin s lymphoma (BCNHL). We report a very rare entity, the case of an 82-year-old female with Child-Pugh class A viral C cirrhosis associated with a primary renal lymphoma (PRL). PRL is a non-Hodgkin s lymphoma (NHL) localized in the kidney, without any involvement of extrarenal lymphatic tissue. In addition to the case report, some relevant data from the literature were reviewed here.

Corresponding author: Laura Paverman, MD, PhD Student; e-mail: laura.paverman@drd.umfcd.ro; Corina-Veronica Lupascu-Ursulescu, Associate Professor, MD, PhD; e-mail: corina.ursulescu@umfiasi.ro

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34. A unique case of recurrent fetal cystic hygroma: first fetus with an inherited heteromorphism of chromosome 1 (1qh+) and the second fetus with 69XXX triploidy

Oana Sorina Tica, Cristina Gug, Andrei Adrian Tica, Cristina Jana Busuioc, Shahram Amiri, Irina Tica, George Bica Brailoiu, Vlad Iustin Tica

The authors report a unique recurrent septated cystic hygroma (CH), on two successive pregnancies, at five years interval. The chromosome analysis of the first fetus showed an increase in length of heterochromatin on the long arm of chromosome 1 - 1qh+, a chromosomal polymorphism inherited from mother, 46XX,1qh+,14ps+,21ps+. The karyotype of the second CH, with more severe ultrasound (US) imaging, showed a 69XXX triploidy. The patient took no risk and underwent each time a termination of pregnancy (TOP). The first karyotype is generally considered normal, although there are few reports linking 1qh+ with low fertility, but this was not the case, the patient having, from a previous marriage, a healthy boy and two TOPs. So, this particular, but healthy karyotype was not a cause for the first CH. The second karyotype highlights a possible causality between the 69XXX triploidy, usually associated with partial hydatidiform mole, and a more severe septated CH in the last fetus. Neither the CHs appearance nor their recurrence seemed to be family linked, as the two CHs had distinct genetic profiles. We recommend that, once CH is diagnosed, a careful US examination is compulsory for the determination of subcutaneous edema, ascites, pleural and pericardial effusions and cardiac or renal abnormalities; an early genetic work-up is mandatory, by chorionic villus sampling or amniocentesis. However, a healthy karyotype does not exclude a severe form, as in our first case of CH. Due to the very poor outcome of fetuses with CH, the patient must be thoroughly informed about the short and the long-term fetal prognosis.

Corresponding author: Andrei Adrian Tica, Professor, MD, PhD; e-mail: ticaandrei2002@yahoo.com; Irina Tica, Associate Professor, MD, PhD; e-mail: irinatica@gmail.com

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35. Unexpected location of endometrial adenocarcinoma - a case report

Mircea-Octavian Poenaru, Liana Ples, Romina-Marina Sima, Petronela Ionescu, Cosmin Florescu, Ilinca Neacsu, Catalina Diana Stanica, Adrian Neacsu

Endometrial adenocarcinoma (ADK) is one of the most common uterine cancer and the fourth neoplasia mortality cause in women according to the literature data. ADK is encountered in the sixth decade of life, the mean age being 63 years. Only 2-5% of cases are found in women less than 40 years old. We present the case of a 63-year-old woman admitted in our Clinic for hypogastric pain and reduced vaginal sanguinolent discharge. The genital examination and transvaginal ultrasound (US) scan were strongly suggestive for a type 0 myoma tending to be expelled through the cervical canal. Laparotomy and total hysterectomy with bilateral adnexectomy were performed. Histological examination identified a grade G1 well-differentiated endometrioid ADK without uterine wall invasion. The immunohistochemistry study for estrogen receptors expression revealed moderate and strong nuclear immunostaining in more than 70% of the tumoral cells, as well as a mosaic p16 immunoexpression, a cytokeratin 7 (CK7) immunophenotype, no p53 overexpression and low Ki67 index (estimated at 10-15%). Considering the incidental finding, the early stage and limited localization of the ADK at the myoma surface level surgery was considered sufficient as treatment but follow-up was conducted by magnetic resonance imaging (MRI) and general examination every six months. The most interesting aspect of the case was the atypical presence of an active myoma in menopause and the totally unsuspicious US appearance of the endometrium. The endometrial ADK was accidentally discovered in an unusual specimen without any other symptom.

Corresponding author: Romina-Marina Sima, Assistant Professor, MD, PhD; e-mail: romina.sima@yahoo.es

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36. Giant and multiple cardiac papillary fibroelastomas masquerading as acute cerebrovascular events

Cosmin Adrian Teodoru, Maria Alexandra Preda, Veronica Madalina Boruga, Marius Cristian Suta, Diana Maria Darabus, Anita-Emese Toth, Leila Al Barri, Remus Florin Cornea, Andrei Emanuel Grigorescu, Diana-Camelia Bonte, Simona Stanca, Horea Bogdan Feier

Cardiac papillary fibroelastomas are rare benign cardiac tumors. Their clinical significance results from their very high propensity for embolization. We present two such cases, which are rare regarding the size and multiplicity of these tumors.

Corresponding author: Marius Cristian Suta, MD, PhD Student; e-mail: sutamarius@yahoo.ro; Diana-Camelia Bonte, MD, PhD; e-mail: dia_bonte@yahoo.com

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37. A fetus with an immature umbilical cord teratoma associated with exomphalos: case report and review of the literature

Andre Miguel Travessa, Susana Santo, Rita Luis, Maria Carvalho Afonso, Rui Carvalho, Emilia Vitorino, Ana Berta Sousa

Objective: To describe the antenatal and pathological features of an immature umbilical cord teratoma associated with exomphalos, and to review the literature on this subject. Case presentation: An abdominal wall defect, suspected to be an exomphalos, was identified during routine ultrasound examination performed at 13 weeks of gestation. The pregnancy was terminated. Fetopathological examination revealed an immature umbilical cord teratoma associated with exomphalos. Chromosomal microarray analysis was normal. Conclusions: Umbilical cord teratomas, albeit very rare, should be emphasized as a possible differential diagnosis when abdominal wall defects are detected. Since cord teratomas may lead to adverse fetal or neonatal outcomes, close follow-up of the fetus is recommended.

Corresponding author: Andre Miguel Travessa, MD; e-mail: andre.travessa@chln.min-saude.pt

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38. The discovery of the circle of Willis as a result of using the scientific method in anatomical dissection

Ana Maria Dumitrescu, Claudia Florida Costea, Andrei Ionut Cucu, Gabriela Florenta Dumitrescu, Mihaela Dana Turliuc, Dragos Viorel Scripcariu, Manuela Ciocoiu, Daniela Maria Tanase, Serban Turliuc, Camelia Margareta Bogdanici, Simona Delia Nicoara, Alexandru Carauleanu, Speranta Schmitzer, Anca Sava

There are numerous articles on the discovery of this arterial polygon, its history being quite long, beginning with the Antiquity and up to the Modern Era. Making an analysis of the primary and secondary sources on this topic, the purpose of this article is to identify the significant moments of the discovery of this arterial polygon, which is an anatomical structure with great importance for neurologists and neurosurgeons. We will present the contributions to this topic from Renaissance and early Modern Era anatomists, such as Andreas Vesalius, Jean Fernel, Gabriel Fallopius, Giulio Cesare Casseri, Adriaan van den Spiegel, Johann Vesling, and Johann Jakob Wepfer von Schaffhausen. We also pointed out that the contribution of the famous British anatomist Sir Thomas Willis (1621-1675) was the most important one. He published De Cerebri Anatome, in 1664, in which he described the vascular arrangement laying at the base of the brain, accompanying it by the exquisite drawings of Christopher Wren. Thus, he demonstrated to the medical world that he had reached the greatest understanding of the structure and function of the circular arterial anastomosis. For this excellent discovery, his followers honored him by giving his name to this arterial circle.

Corresponding author: Claudia Florida Costea, Associate Professor, MD, PhD; e-mail: costea10@yahoo.com; Andrei Ionut Cucu, MD, PhD Student; e-mail: andreiucucu@yahoo.com

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39. Letter to the Editor: Boron enhances the antiviral activity of the curcumin against SARS-CoV-2

Ion Romulus Scorei, Andrei Bita, George Dan Mogosanu

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Corresponding author: Ion Romulus Scorei, Professor, Biochem, PhD; e-mail: romulus_ion@yahoo.com

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