ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 62 No. 2, April-June 2021

1. The Myth of Prometheus in metastatic meningioma to the liver: from craniotomy to hepatectomy

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

Metastases from intracranial meningiomas are rare, and among them, meningiomas with hepatic dissemination are extremely rare. Therefore, there are currently no guidelines for staging and treatment of metastatic disease in meningioma, a disease that is a challenge for both the clinician and the pathologist. Our literature review revealed 24 cases of liver metastases originating from intracranial meningiomas. We used them to analyze the pathological patterns of dissemination and to assess the different management strategies available, the most efficient and beneficial being surgery and chemotherapy, especially in the case of meningiomas with hepatic and/or systemic dissemination.

Corresponding author: Andrei Ionut Cucu, MD, PhD; e-mail: andreiucucu@yahoo.com; Dragos Viorel Scripcariu, MD, PhD; e-mail: dscripcariu@gmail.com

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2. Giant left atrial myxoma - literature review and case presentation

Victor Cornel Raicea, Horatiu Suciu, Andrei Dan Raicea, Gheorghe Cosmin Macarie, Tibor Mezei, Maria Smaranda Maier

Primary cardiac tumors are an extremely rare pathology, representing only 5-10% of cardiac neoplasms, but among them, the most common are cardiac myxomas, that appear to originate from multipotent mesenchymal cells of the subendocardial and endocardial stroma. The incidence of cardiac myxomas is higher in females and they are usually diagnosed between the fourth and sixth decade of life. Most often, they are located in the left atrium, having the site of attachment at the level of the interatrial septum, especially at the level of the fossa ovalis and the adjacent limbus. Due to the increased risk of systemic embolization and intracardiac obstruction, cardiac myxomas have a definite indication for emergency surgical treatment. Cardiac myxomas are a very rare cause of transient ischemic attacks and stroke. We present the case of a 38-year-old patient who experienced four recurrent transient ischemic attacks and strokes. At the fourth cerebrovascular event, echocardiography was performed and it revealed a giant tumor located in the left atrium that was surgically removed. Pathological examination confirmed the diagnosis of cardiac myxoma. The postoperative evolution was favorable, both from a neurological and cardiac point of view. Although cardiac myxomas represent a rare cause of transient ischemic attacks and stroke, they must be considered as part of the assessment protocol for cerebrovascular events.

Corresponding author: Andrei Dan Raicea, MD; e-mail: raicea_andrei@yahoo.com

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3. Clinical and pathological aspects of condyloma acuminatum - review of literature and case presentation

Damian Ditescu, Anca-Maria Istrate-Ofiteru, Gabriela-Camelia Rosu, Larisa Iovan, Ilona Mihaela Liliac, George-Lucian Zorila, Maria Balasoiu, Liliana Cercelaru

Condyloma acuminatum (CA) is a pathology caused by the human papillomavirus (HPV). It is manifested by the appearance of warts in the vulvar, pubic, and anorectal regions, but can occur in other areas. It is a common disease that can be prevented by using measures such as condoms or vaccine. Topical, local, pharmacological, surgical, and excisional therapy options are available for this pathology. Macroscopically, it appears as a vegetative tumor, with a single implantation base that branches towards the periphery, with a cauliflower appearance. CA is defined microscopically by acanthosis, parakeratosis, papillomatosis and koilocytosis. Immunohistochemical studies can detect the presence of various HPV strains or viral antigens and can emphasize certain specific characteristics; e.g., in the case presented in this study, we observed that the tumor had a fulminant evolution due to a strong vascular base identified with anti-cluster of differentiation (CD) 34 antibody, by the existence of epithelial cells with a high degree of cell proliferation, as evidenced by the anti-Ki67 antibody, the inactivation of the tumor suppressor gene and the appearance of immunolabeling for the anti-p53 antibody, by the strong immunoreactivity for p63 which reveals the existence of cells with dysplastic and neoplastic transformation potential, but also by detecting the immunolabeling for p16INK4a that is associated with the existence of HPV. Also, the tumor was immunoreactive for cytokeratin (CK) AE1/AE3, partially immunoreactive for CK5/6 in the basal layer and negative for CK7, which demonstrates the squamous epithelial origin of the described tumor. Subepithelial cells of the inflammatory system have been identified, such as macrophages immunolabeled with anti-CD68 antibody, T-lymphocytes immunolabeled with anti-CD3 antibody and rare B-lymphocytes immunolabeled with anti-CD20 antibody, which demonstrates the strong cellular response to remove the virus from the structure. Surgical and excisional treatment was helpful for the patient, because she was able to resume normal sexual activity and defecation, and on the other hand, microscopic studies showed the potential for malignant transformation of CA.

Corresponding author: Gabriela-Camelia Rosu, Teaching Assistant, MD, PhD; e-mail: nicola_camelia92@yahoo.com; Ilona Mihaela Liliac, MD, PhD Student; e-mail: ilona.mihaela.liliac@gmail.com

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4. Practical aspects regarding the histopathological grading and anaplastic transformation of gangliogliomas - a literature review

Antonia Carmen Lisievici, Mihai Gheorghe Lisievici, Diana Pasov, Tiberiu Augustin Georgescu, Octavian Munteanu, Corina Grigoriu, Roxana Elena Bohiltea, Florentina Ligia Furtunescu, Maria Sajin

Ganglioglioma represents a benign central nervous tumor, occurring predominantly in the pediatric population and affecting the temporal lobe. It is also renowned for its epileptogenic potential. However, to date, there are numerous uncertain features about this tumor, especially about its grading system. In the former World Health Organization (WHO) Classification of central nervous tumors system, gangliogliomas could have been attributed one out of three grades: grade I (benign), grade II (atypical), and grade III (anaplastic). The new classification systems have renounced to atypical ganglioglioma nomenclature, due to the lack of histopathological criteria for this entity. Another controversial aspect of grade I ganglioglioma is its potential to transform into a malignant tumor, namely, most frequently an anaplastic ganglioglioma. Based on our knowledge, there are no literature reviews to date focusing on anaplastic transformation potential. The present paper encompasses all anaplastic transformation of gangliogliomas and has analyzed the time frame between the two events, the age of the patients and its relationship to the complete or subtotal resection and administration of radiotherapy. Thirty-three cases of malignant transformation of ganglioglioma have been reported so far in the literature, with 54.54% of them undergoing progression to anaplastic ganglioglioma and 21.21% to anaplastic ganglioglioma. Median age was 26 years, and the cases were evenly distributed between the two genres. Only 27.27% of all evaluated cases had been administrated adjuvant radiotherapy, and only 44% of the latter have had an incomplete tumoral resection.

Corresponding author: Tiberiu Augustin Georgescu, Assistant Professor, MD, PhD; e-mail: tiberiuaugustin.georgescu@gmail.com; Roxana Elena Bohiltea, Associate Professor, MD, PhD; e-mail: r.bohiltea@yahoo.com

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5. The differential diagnosis of ulcerative colitis versus angiodysplasia of the colon with ischemic colitis

Denisa Elena Popa, Mihaela Calita, Mihail Cristian Pirlog, Cristian Constantin, Cristiana Gabriela Popp, Dan Ionut Gheonea

Ulcerative colitis and Crohn s disease are the inflammatory bowel diseases with a continuously increasing of prevalence. Their exact causes are still not well known and, more than that, they are raising up serious issues of diagnosis. The same difficulties of diagnosis are encountered in the case of the colonic angiodysplasia or ischemic colitis (IC). Colonic angiodysplasia is a common vascular abnormality of the gastrointestinal tract, being diagnosed mostly in the elderly persons, in a similar manner to the IC. For all these diseases comorbidities plays their important role both as causes of the onset and aggravating factors during the evolution. The differential diagnosis between these three conditions needs a complex and multidisciplinary approach, involving at least clinical evaluation, endoscopic and imaging assessments, and histopathological exam.

Corresponding author: Mihail Cristian Pirlog, Associate Professor, PhD; e-mail: mihail.pirlog@umfcv.ro

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6. The efficiency of using enamel matrix derivative in therapeutic approach of periodontal furcation defects of maxillary and mandibular molars

Anca Silvia Dumitriu, Andreea Cristiana Didilescu, Marina-Cristina Giurgiu, Stefan-Dimitrie Albu, Cristiana Elena Padure, Ximena Anca Nicolae, Stana Paunica

Periodontal disease is an inflammatory condition which affects the covering and support structures of the teeth and, if left untreated, leads to tooth loss. Resorption of the alveolar bone from bi- and trifurcation regions of a multirooted tooth due to the progression of a periodontal disease bears involvement furcation. The degree of furcation involvement is clinically assessed by changes in the vertical and horizontal plane at the root separation area. In the approach of the furcation treatment, the morphological and functional particularities of pluriradicular teeth must be considered and the current techniques look for solutions for the regeneration of the destroyed periodontal tissues. Enamel matrix derivative (EMD) has the role of stimulating healing processes through effects on various growth factors, cement formation, angiogenesis and are used single or in combination with bone graft substitute (BGS) or guided tissue regeneration (GTR) in the complex treatment of periodontal disease. The present study follows PubMed publications on the efficiency of EMD in the treatment of pluriradicular tooth furcations. The findings are that there are not many studies in the usage of EMD associated with the treatment of furcations, but it is an important choice in the complex treatment of destructive periodontal disease, and further studies are needed to be done in periodontal regeneration.

Corresponding author: Marina-Cristina Giurgiu, Lecturer, DMD, PhD; e-mail: giurgiu.marina@yahoo.com; Stefan-Dimitrie Albu, Assistant Professor, DMD; e-mail: stevealbu@yahoo.com

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7. Assessment of clinical and pathological complete response after neoadjuvant chemoradiotherapy in rectal adenocarcinoma and its therapeutic implications

Sorin Tiberiu Alexandrescu, Adrian Vasile Dumitru, Ruxandra Doina Babiuc, Radu Virgil Costea

Because almost one fourth of patients with rectal adenocarcinoma (RC) achieve pathological complete response (pCR) after neoadjuvant chemoradiation therapy (CRT), having significantly higher survival rates than those without pCR, the assessment of pCR represents a highly important challenge nowadays. Moreover, recent studies revealed that organ-sparing approaches could represent a reasonable alternative to radical surgery (RS) in patients with pCR, achieving similar long-term outcomes with lower morbidity rates and improved quality of life. Unfortunately, the decision of a rectum-sparing approach should be based only on clinical, endoscopic (with or without biopsy) and radiological methods, that must accurately predict the pCR after neoadjuvant CRT, in the absence of the pathological examination of the RS specimen. Thus, a surrogate parameter called clinical complete response (cCR) emerged, to assess the results of neoadjuvant CRT. The evolving accuracy of recent endoscopic and imaging methods in assessment of cCR and their predictive value for estimation of pCR achievement are presented. The usefulness of combining the results of these evaluation methods (resulting in the development of few nomograms) for a more accurate estimation of pCR, as well as the predictive factors for pCR achievement are also debated. Moreover, the changing landscape of therapeutic approaches based on cCR assessment is discussed, emphasizing the advantages and pitfalls of rectum-sparing approaches, compared to RS. Because there are no reliable methods to estimate with 100% accuracy the pCR, the only way to decrease as much as possible the risk of misleading treatment choices is the multidisciplinary team-based decision.

Corresponding author: Ruxandra Doina Babiuc, Assistant Professor, MD, PhD; e-mail: ruxandra.babiuc@umfcd.ro

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8. E-cadherin and aquaporin 1 co-expression analysis in hepatocellular carcinoma: a pilot study

Ana-Maria Ciurea, Cristin Constantin Vere, Cristiana Gabriela Popp, Costin Teodor Streba, Mihaela Calita, Daniel Pirici, Liliana Cercelaru, Michael Schenker, Dan Ionut Gheonea, Ionica Pirici

Hepatocellular carcinoma (HCC) is the main primary liver malignancy, being associated with both health and economic burden worldwide. Recently, novel molecular markers and possible therapeutic targets were identified. Different adhesion molecules, as well as possible angiogenesis-associated targets can be prime candidates when investigating novel therapies. Considering these premises, our goal was to study the co-existence of E-cadherin and aquaporin 1 (AQP1) in a series of HCC diagnosed patients. Utilizing archived tissue fragments from 17 patients diagnosed with well-to-moderate and poorly differentiated HCC, as well as four samples of normal liver tissue and using a highly specific biotin-free tyramide amplification technique, we have assessed here the expression of E-cadherin and AQP1 during HCC carcinogenesis. Moreover, as we have observed that some of the AQP1 expression seems membrane-bound, we have sought to evaluate their co-localization. Our data showed, as expected, that E-cadherin decreases from control tissue to low-grade and respectively, high-grade HCC. AQP1 was expressed, also as already known, at the level of endothelial blood vessels and bile ducts epithelia, however, we have showed here for the first time that this water pore is also expressed in the cytoplasm and membranes of hepatocytes, both in control and HCC tissue. Moreover, AQP1 expression parallels the decrease of E-cadherin expression during carcinogenesis, but together with this downregulation, we have also found a spatial decrease in the colocalization of the two proteins. Altogether, utilizing a biotin-free tyramide signal amplification technique, this study shows for the first time that AQP1 is expressed at the level of liver epithelia, in both control and HCC tissue.

Corresponding author: Costin Teodor Streba, Professor, MD, PhD; e-mail: costin.streba@umfcv.ro; Mihaela Calita, PhD; e-mail: mihaelacalita@yahoo.com

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9. Brain metastases originating in breast cancer: clinical-pathological analysis and immunohistochemical profile

Anca Sava, Claudia Florida Costea, Ruxandra Vatavu, Mihaela Grigore, Mihaela Dana Turliuc, Gabriela Florenta Dumitrescu, Lucian Eva, Andrei Gheorghe Marius Motoc, Cristinel Ionel Stan, Liviu Ciprian Gavril, Sadiye Ioana Scripcariu

The incidence of brain metastases (BMs) originating in breast cancer (BC) is increasing due to advances in imaging techniques, which can detect such events early, and due to new therapies that can ensure longer survival. We performed a retrospective study on patients with BMs originating in BC and receiving surgical treatment in Neurosurgery Clinics of Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iasi, Romania, from January 2018 to December 2019. We identified 10 consecutive patients who underwent a craniotomy for a BMs originating in a BC (either for diagnostic purpose or with therapeutic intent). Clinicopathological data were collected from the electronic medical record and included the patient demographics (age at diagnosis of their BM), morphological characteristics of BM [location, cytopathological features, histopathological (HP) subtype, and immunohistochemical features, i.e., cytokeratin 5/6 (CK5/6), mammaglobin, estrogen receptor (ER), progesterone receptor (PR), and Ki67 labeling index (LI)], and time from BC diagnosis to BM diagnosis. Ninety percent of patients were in their sixth and seventh decades of life, with a median age of 57.9 years (47-65 years). Median time from BC diagnosis to BM was 34.42 months. Fifty percent of BMs were located in the parietal lobes, and 70% of all cases have multiple (>=2) BMs. All cases (100%) had a cytopathological examination, showing a hypercellular pattern, with poorly cohesive clusters of mild or pleomorphic cells, with nuclei with homogeneously distributed fine granular chromatin membrane, and with small or enlarged and irregular nucleoli. The dominant histopathology was invasive breast carcinoma of no special type (IBC-NST) (70%), but we also identified specific subtypes, i.e., tubular carcinoma (TC) (20%) and invasive micropapillary carcinoma (IMPC) (10%). Correlating location with HP subtypes of BMs from BC, IBC-NST and IMPC were located mostly in parietal lobes, and TC developed only in the occipital lobe. We found three patterns of immunostaining: (i) CK5/6 +/-, mammaglobin+, ER+, PR-, which was much more characteristic for IBC-NST; (ii) CK5/6-, mammaglobin+, ER-, PR-, being identified in tubular breast carcinoma; (iii) CK5/6 +/-, mammaglobin-, ER-, PR-, which were revealed by invasive micropapillary breast carcinoma. Our study revealed the fact that BMs originating in BC show heterogeneity of hormone receptor status, although morphologically there is not so much diversity. We also found a very variable Ki67 LI, which correlated especially with the morphological subtype.

Corresponding author: Claudia Florida Costea, Associate Professor, MD, PhD; e-mail: costea10@yahoo.com; Ruxandra Vatavu, MD, PhD Student; e-mail: ruxandravatavu@yahoo.com

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10. Clinical, histopathological and immunohistochemical study of keratoacanthoma

Alina Maria Vilcea, Loredana Elena Stoica, Claudia Valentina Georgescu, Florina Carmen Popescu, Raluca Niculina Ciurea, Ionica Daniel Vilcea, Cecil Sorin Mirea

Keratoacanthoma (KA) is an epithelial tumor of the skin, classically considered as having a malignant transformation risk of 15%; however, many authors and the new World Health Organization (WHO) Classification of skin tumors consider KA as an incipient variant of the cutaneous squamous cell carcinoma (SCC). The aims of the study were to assess the clinical, histopathological (HP) and immunohistochemical (IHC) aspects of the KA and the role of these factors in malignancy occurrence. The studied group comprises 194 patients diagnosed with KA or malignant KA, hospitalized in the Clinic of Dermatology, Emergency County Hospital, Craiova, Romania, between 2006 and 2019. There were 83 males and 111 females, aged 34 to 90 years, 57.21% of the patients being from the rural environment. The histopathology diagnosed 51 KAs and 143 malignant KAs (SCCs). Clinical diagnosis had a limited value in detecting the absence or presence of malignancy in the KA lesion, due to a low accuracy (36.08% and 29.89%, respectively) and specificity (23.07% and 27.02%, respectively); therefore, the HP exam of the surgical excision specimen has a paramount importance in establishing the diagnosis. IHC analysis revealed that the immunostainings for apoptosis-associated proteins and keratinocyte proliferative activity [p53, B-cell lymphoma-2 (Bcl-2), Ki-67 and proliferating cell nuclear antigen (PCNA)] provide some arguments to differentiate between KA and SCC in the studied cases. The correlation of clinical, HP and IHC data lead to an accurate diagnosis of KA; moreover, the clinical, HP and IHC data sustain the idea that KA is a particular form of well-differentiated SCC, which require an active therapeutic attitude.

Corresponding author: Loredana Elena Stoica, Associate Professor, MD, PhD; e-mail: tanaseloredanaelena@yahoo.com

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11. Neuroendocrine tumors (NETs) - experience of a single Center

Mihaela Cornelia Sincu, Iuliu Gabriel Cocuz, Andreea Catalina Tinca, Raluca Niculescu, Adrian-Horatiu Sabau, Diana Maria Chiorean, Silviu Horia Morariu, Ovidiu Simion Cotoi

Introduction: Neuroendocrine neoplasms (NENs) are a heterogeneous group of tumors arising from cells that are part of the diffuse neuroendocrine system. Patients, Materials and Methods: We conducted a retrospective study in which we included a number of 91 cases diagnosed with neuroendocrine tumors (NETs). Descriptive statistics was performed: number of cases based on location, distribution by gender (male/female), distribution by age, and we also performed a morphological and immunohistochemical (IHC) study. Results: The highest number of cases was found in lungs (60 cases). Tumors located on the skin, breast or bladder have been discovered, locations considered rare for this type of tumor. Of all cases diagnosed in the lungs, 59 were diagnosed as small cell carcinomas (SCCs) and only one case as NET. All surgical specimens were positive for chromogranin A (CgA), with a different expression for the other immunomarkers. For the lung biopsies, the most frequently IHC staining was CgA and cluster of differentiation 56 (CD56), with an increased positivity for the latter. Conclusions: CgA remains the most sensitive immunomarker in the diagnosis of NETs. CD56 is the most widely used immunomarker for diagnosing small cell lung tumors. Positive expression of thyroid transcription factor 1 (TTF1) immunomarker does not confirm pulmonary origin of SCCs.

Corresponding author: Iuliu Gabriel Cocuz, Assistant, MD, PhD Student; e-mail: iuliu.cocuz@umfst.ro

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12. The pioneer use of a modified PRGF-Endoret technique for wound healing in a hemodialyzed diabetic patient in a terminal stage of renal disease

Ioana Adela Ratiu, Cristian Adrian Ratiu, Viorel Miclaus, Adina Bianca Bosca, Rumeyza Turan Kazancioglu, Anne Marie Constantin, Gabriel Cristian Bako, Alina Simona Sovrea

In the literature, this paper is the first to describe the use of plasma rich in growth factors (PRGF)-Endoret in hemodialyzed diabetic patients, to promote the healing of after amputation wounds. The PRGF-Endoret was primarily conceived to be used in maxillofacial surgery, oral implantology, etc., the innovation residing in the blood collection technique (quantity, moment of the week, rhythmicity), which was adapted to the specific conditions of the hemodialyzed patient. Moreover, in the initial phases, the two PRGF fractions were innovatively applied as single alternating layers on the wound surface. Only after the surface of the wound decreased, the two PRGF fractions were applied as overlapping layers. Nevertheless, the paper presents the optimal method to assess the clinical evolution of the wound. Histopathological examination of the biopsy performed during wound preparation for PRGF application brought additional, essential data for orienting the therapeutic approach. The exclusion of calciphylaxis, a disease with high mortality risk, encouraged the application of this method, and also demonstrated the microscopic features in hemodialyzed diabetic patients.

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

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13. Triglyceride and glucose index: a useful tool for non-alcoholic liver disease assessed by liver biopsy in patients with metabolic syndrome?

Anca Maria Amzolini, Mircea Catalin Fortofoiu, Anca Barau Abu-Alhija, Ionela Mihaela Vladu, Diana Clenciu, Adina Mitrea, Maria Fortofoiu, Daniela Matei, Viorela Enachescu, Octavian Ion Predescu, Elena Simona Micu

Introduction: Non-alcoholic fatty liver disease (NAFLD) is associated with metabolic impairments, being a component of metabolic syndrome. Considering the involvement of fat accumulation and insulin resistance in NAFLD, triglyceride and glucose (TyG) index was proposed as a marker of NAFLD progression. The gold standard for the evaluation of liver lesions characteristic for NAFLD remains the liver biopsy. The aim of this study was to establish the links between TyG index, assessing insulin resistance, and histopathological lesions of liver samples obtained by liver biopsy in patients with metabolic syndrome. Patients, Materials and Methods: We conducted a study over a period of three years, including 113 adult patients with metabolic syndrome in whom hepatic disorders were assessed by liver biopsy and insulin resistance was evaluated by TyG index. Results and Discussions: In our study, steatosis had a frequency of 92.03%, being identified 26 cases with mild steatosis, 48 with moderate steatosis and 31 with severe steatosis. Regarding non-alcoholic steatohepatitis (NASH), the frequency of this disorder in our study group was 29.2% in the subjects with liver steatosis, while liver fibrosis had a frequency of 53.09%. When we analyzed the relationships between TyG index and the presence of each type of lesion necessary for NASH diagnosis, we obtained statistically significant differences for the presence of hepatocyte ballooning (p=0.01) and a high statistically significance for the NAFLD activity score (NAS) (p<0.0001). Conclusions: TyG index is a facile tool that can be used to identify patients at risk for advanced NAFLD lesions evaluated by liver biopsy.

Corresponding author: Ionela Mihaela Vladu, Assistant Professor, MD, PhD; e-mails: ionela.vladu@umfcv.ro, mihmitzu@yahoo.com; Octavian Ion Predescu, Lecturer, MD, PhD; e-mail: octavian_predescu@yahoo.com

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14. Adenoidal bacterial biofilm in pediatric rhinosinusitis

Radmila-Anca Bugari, Aristide Sorin Baschir, Luminita Adela Turcin, Alexandru Chioreanu, Ciprian Valentin Mihali, Adrian Cosmin Ilie, Afilon Jompan, Maria Balasoiu

The aim of the study was to observe, using scanning electron microscopy (SEM), the ratio of bacterial biofilm coverage of adenoidal tissue in children diagnosed with chronic rhinosinusitis (CR), compared to the ratio of adenoid bacterial biofilm coverage in children diagnosed with obstructive sleep apnea (OSA). We also performed histopathological and immunohistochemical tests to correlate the results with the images obtained from SEM. We estimated, using an image analysis program, the coverage ratio with bacterial biofilm on the surface of the lymphatic tissue. Adenoid vegetation extracted from children with CR had a higher percentage of bacterial biofilm coverage compared to the group diagnosed with OSA. In the nasopharynx of children with CR, the bacterial biofilm had a constant role of infection generator, and adenoidectomy was the only effective therapeutic procedure to relieve the symptoms. Allergy tests were performed in all children to establish a link between CR, OSA and allergic rhinitis.

Corresponding author: Alexandru Chioreanu, MD, PhD Student; e-mail: alexandru.chioreanu@yahoo.ro; Maria Balasoiu, Professor, MD, PhD; e-mail: balasoiu.maria@yahoo.com

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15. Association between genetic variants and depression in a Romanian cohort

Andrei Costache, Anca-Lelia Riza, Mihaela Popescu, Ioana Streata, Mihaela-Eugenia Dinca, Daniela Gabriela Glavan, Ionela Mihaela Vladu, Ion Udristoiu, Mihai Ioana

Major depressive disorder (MDD) is beyond doubt a common, disabling, and costly condition. MDD associates hypothalamic-pituitary-adrenal (HPA) axis alterations. We sought to investigate two candidate variants which could have a role in the genetic susceptibility for stress or corticoid-induced MDD: glucocorticoid receptor (GR) - nuclear receptor subfamily 3 group C member 1 (NR3C1) rs41423247 and brain-derived neurotrophic factor rs6265 BDNF:c.442G>A Val66Met. We enrolled 82 Romanian subjects, 1:2 male to female ratio, 53.54+/-8.98 years old, diagnosed with an episode of major depression at the Clinical Neuropsychiatry Hospital in Craiova, Romania, and 286 healthy controls, 34.28+/-16.34 years old. All subjects were genotyped using specific ThermoFisher Scientific assays on a ViiA 7 real-time polymerase chain reaction (PCR) system. The impact of certain genetic variants may be ethnic-specific. In our Romanian cohort, rs41423247 NR3C1:c.1184+646C>G has a minor allele frequency of 29.2%, and rs6265 BDNF:c.442G>A of 22.2%. Neither reached significance in our study, under any of the association models - dominant, recessive, or allelic. Interpretation of our negative findings requires caution: literature provides arguably more evidence for the association between the analyzed polymorphisms; our study has sample size challenges, from which refined phenotyping limitations derive.

Corresponding author: Mihaela Popescu, Lecturer, MD, PhD; e-mail: mihaela.n.popescu99@gmail.com

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16. Impairment of the cardiac ejection fraction by blocking dopamine D2 receptors induced by long-acting injectable antipsychotic treatment

Liana Dehelean, Ileana Marinescu, Puiu Olivian Stovicek, Ana Maria Romosan, Radu Stefan Romosan, Rita Balint, Bianca Oana Bucatos, Andra Vera Livia Ciobanu, Mariana Bondrescu, Dragos Marinescu, Marinela Minodora Manea, Valentina Oana Buda, Minodora Andor, Adela Magdalena Ciobanu

Introduction: Atypical antipsychotics have numerous benefits compared to conventional ones in respect to the possible adverse effects. However, like the other ones, they may induce direct cardiovascular alterations, probably through the apoptotic effect of dopamine receptor D2 (DRD2) blockade. The main objective of the study was to assess the cardiac ejection fraction (EF) using transthoracic speckle tracking echocardiography (TSTE) in patients treated with long-acting injectable (LAI) atypical antipsychotics. Patients, Materials and Methods: This cross-sectional study was conducted on 123 patients with schizophrenia or schizoaffective disorder divided in four samples according to their treatment: Aripiprazole, Olanzapine, Paliperidone and Risperidone. We analyzed socio-demographic data, the intensity of psychiatric symptoms, the duration of psychosis and of LAI treatment, and the cardiac EF measured with TSTE. Results: We found no statistically significant differences between the four antipsychotics regarding the values of the EF. Nevertheless, we observed a trend indicating that patients treated with an antipsychotic associated with a lower affinity for the DRD2, such as Olanzapine, have higher EF values than patients treated with antipsychotics with a stronger binding to the DRD2, such as Paliperidone and Risperidone. Patients receiving Aripiprazole, which has the strongest affinity for the DRD2 from all four antipsychotics but is also a partial DRD2 agonist, display higher EF values than those on Paliperidone and Risperidone. Conclusions: Antipsychotics with a lower affinity for the DRD2 or a partial agonism for it may be associated with higher EF. Cardiac monitoring should be performed periodically in patients on LAI antipsychotic therapy.

Corresponding author: Ileana Marinescu, Associate Professor, MD, PhD; e-mail: marinescu_psy@yahoo.com; Puiu Olivian Stovicek, Lecturer, MD, PhD; e-mail: puiuolivian@yahoo.com

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17. Systemic and adipose tissue inflammation in NASH: correlations with histopathological aspects

Elena Simona Micu, Anca Maria Amzolini, Anca Barau Abu-Alhija, Mircea Catalin Fortofoiu, Ionela Mihaela Vladu, Diana Clenciu, Adina Mitrea, Stelian Stefanita Mogoanta, Anda Elena Crisan, Octavian Ion Predescu, Mirela Radu

Introduction: Non-alcoholic steatohepatitis (NASH) is a progressive form of liver steatosis that involves a risk of progression towards fibrosis, cirrhosis, and end-stage liver disease. Low-grade inflammation is recognized to be involved in non-alcoholic fatty liver disease (NAFLD) pathogeny. Additionally, adipose tissue dysfunction plays an important role in the development of metabolic diseases. Patients, Materials and Methods: We conducted a study on 68 patients with liver steatosis confirmed through liver biopsy during the surgery. In all the patients, we recorded anthropometric parameters and we performed blood tests for systemic inflammation [high-sensitivity C-reactive protein (hs-CRP), fibrinogen] and serum adipokines related to adipose tissue inflammation (leptin, adiponectin). Additional to histopathological examination, we also performed the immunohistochemical study of inflammatory mononuclear cells. Results: The 68 patients had a mean age of 56.57+/-4.94 years old, had a mean value of hs-CRP of 2.30+/-0.91 mg/L, a mean value of leptin of 14.02+/-17.02 ng/mL and a mean value of adiponectin of 7.54+/-0.38 mg/L. In all the cases studied by liver biopsy, the steatosis exceeded 5% of hepatocytes, but the frequency of NASH was 26.47%. Cluster of differentiation (CD)45-positive, CD4-positive, and CD8-positive T-lymphocytes predominated in the studied cases. We obtained a statistically significant high association between definite NASH and the values of hs-CRP, serum adiponectin and leptin/adiponectin ratio (p<0.0001). Conclusions: Systemic and adipose tissue inflammation was statistically significant associated with histological lesions of steatosis and NASH, suggesting that the determination of hs-CRP and serum adipokines in dynamics in patients with NAFLD is predictive for the progression of the disease.

Corresponding author: Anca Maria Amzolini, University Assistant, MD, PhD; e-mails: anca.amzolini@umfcv.ro, amzolinianca@yahoo.com; Octavian Ion Predescu, Lecturer, MD, PhD; e-mail: octavian_predescu@yahoo.com

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18. Morphometric study for determining the anteroposterior position of the mental foramen in dentate human subjects

Ovidiu Romulus Gherghita, Irma Eva Csiki, Elena Nicoleta Bordea, Angelo Pellegrini, Suzana Carmen Cismas, Natalia Motas, Vanda Roxana Nimigean, Victor Nimigean

Background: The mental foramen (MnF) is the place where the mental nerve and mental artery exit the body of the mandible, being an important landmark for dentoalveolar surgery. Materials and Methods: For the assessment of MnF topography, we performed a direct morphometric study and two morphometric imaging studies through cone-beam computed tomography (CBCT) scans and orthopantomography (OPG). The following locations of the MnF were investigated: anterior to the first premolar, at the first premolar level, between the two premolars, at the second premolar level, between the second premolar and the 6-year molar, and at the level of the mesial root of the 6-year molar. The data obtained were statistically analyzed by chi-squared test. Results: Through direct morphometry on dentate dry human mandibles, no statistically significant differences were found for the number of MnF located between the two premolars, at the level of the second premolar and between the second premolar and the 6-year molar, depending on age and analyzed side. The number of MnF located between the second premolar and the first molar varies statistically significantly in relation to the subject s gender but does not vary statistically significantly depending on age and side. By means of imaging morphometry through OPG, we found that the number of MnF located at the first premolar level, between the two premolars, at the second premolar level and between the second premolar and the 6-year molar varies statistically significantly in relation to the age of the patients. Using imaging morphometry trough CBCT scans, we found that the number of MnF located between the two premolars, at the second premolar level and between the second premolar and the 6-year molar varies statistically significantly according to the age of the patients. Comparing the results obtained from the three studies, we found that only according to age the number of MnF located between premolars and at the level of the second premolar varies statistically significantly. Conclusions: Wide and accurate knowledge of both the MnF topography and the key anatomical landmarks used in locating it proves to be essential and clinically relevant in dentoalveolar and endodontic surgery, and for improving anesthesia techniques.

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

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19. Evaluation of cytotoxic activity and anticancer potential of indigenous Rosemary (Rosmarinus officinalis L.) and Oregano (Origanum vulgare L.) dry extracts on MG-63 bone osteosarcoma human cell line

Cerasela Elena Gird, Teodora Costea, Valentina Mitran

We aimed to investigate the cytotoxic activity of indigenous Rosemary and Oregano freeze-dried extracts upon MG-63 osteosarcoma human cell line. We have determined the influence of analyzed dry extracts on cell morphology, cell survival and cell proliferation. The evaluation of dry extracts effect upon cell proliferation and viability was assessed by means of 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT) method. For cytotoxicity evaluation, Live and Dead and lactate dehydrogenase assays have been used. To further investigate the potential anticancer effect, we have studied the influence of dry extracts upon cells, by means of caspase-3/7 assay and proliferation cell nuclear antigen (PCNA) expression. Cells were incubated with extracts in the following concentration range (100-700 micro-g/mL) for 24 hours. According to our results, both dry extracts have shown cytotoxic effects by means of all used methods. Bone osteosarcoma cells viability significantly decreased with increasing concentration of analyzed extracts (beyond 300 micro-g/mL for Rosemary dry extract and only at 700 micro-g/mL for Oregano dry extract). According to our results, apoptosis is one of the main mechanisms involved in the cytotoxic properties of analyzed extracts. Moreover, Rosemary extract has also shown decreased expression of PCNA, when compared to control (untreated cells). Both extracts were standardized in phenolic compounds (being a rich source of flavones and phenolcarboxylic acids), so we assume that these are the main constituents involved in the cytotoxic effect. Still, further preclinical studies are needed to confirm the antitumor properties and to go deeply in the molecular mechanisms involved.

Corresponding author: Teodora Costea, Associate Professor, Pharm, PhD; e-mail: teodora.costea@umfcd.ro

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20. Morphological aspects in remineralizing potential of Silver Diamine Fluoride

Laura Idorasi, Emanuela Lidia Craciunescu, Adrian Tudor Stan, Cosmin Sinescu, Ana Codruta Chis, Darian Onchis-Moaca, Mihai Rominu, Meda Lavinia Negrutiu

Objectives: The purpose of this study was to demonstrate the efficacy of Silver Diamine Fluoride (SDF) antibacterial solution in penetrating the demineralized areas of enamel. Materials and Methods: It was considered a group of four extracted teeth (with no color fading, fissures, decay, or demineralization). Each tooth was sectioned in two equal parts, in mesio-distal direction, using a dental handpiece and a special rounded, flat bur. Each specimen was demineralized, for one minute, with 45% orthophosphoric acid, on occlusal and proximal zones. The specimens were then washed and dried with water-air dental syringe. All the probes were inspected with an optical microscope and enamel thickness was digitally measured. Advantage Arrest (Elevate Oral Care, USA), which contains SDF, was applied on the previous demineralized zones. The penetration of the substance was visually inspected with the optical microscope and electronically measured. Results: It was observed an improvement in remineralizing the white spots on enamel surfaces, the optical microscope being able to detect both demineralization and the penetration of SDF through enamel. Conclusions: Based on our in vitro study, SDF (Advantage Arrest) was capable to induce/increase enamel remineralization, through SDF penetration.

Corresponding author: Emanuela Lidia Craciunescu, Lecturer, MD, PhD; e-mail: emanuelapetrescu@yahoo.com

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21. High-frequency ultrasound: an essential non-invasive tool for the pre-therapeutic assessment of basal cell carcinoma

Raluca-Maria Bungardean, Mircea-Sebastian Serbanescu, Horatiu Alexandru Colosi, Maria Crisan

Aim: While histology remains the gold standard for cutaneous tumoral pathology, high-frequency ultrasound (HFUS) was shown to play a significant role in the non-invasive, pre-therapeutic assessment of skin tumors. The aim of our study was to determine whether there is a significant correlation between the ultrasound (US) and histological measurements of basal cell carcinoma (BCC) tumor depth. Materials and Methods: The present study retrospectively analyzed clinical, dermoscopy, HFUS and histological examinations of 90 patients (52 men and 38 women) with histologically confirmed BCC, with focus on tumor depth index (DI). Results: On clinical examination, 54 lesions were nodular (32 presented ulcerations) and 36 superficial lesions. Dermoscopy showed suggestive signs of BCC, most frequently in focus arborising superficial vessels (n=81), blue-grey ovoid nests (n=48) and specks of brown pigment (n=7). HFUS revealed well-defined (n=88) or poorly defined (n=2) hypoechoic, vascularized lesions, with inhomogeneous structure (n=90) and characteristic hyperechoic dots (n=36). A strong correlation (Pearson s r=0.92) between the HFUS (mean measured US depth = 1.33 mm) and histological (mean measured histological depth = 1.47 mm) DI of the investigated skin lesions was found, although significant differences (p<0.001 - t-test for paired samples) between the two measurements were observed. Conclusions: HFUS provides reliable information about BCC depth of invasion that cannot be otherwise obtained prior to surgery. In this manner, it completes the preclinical evaluation and can have an impact on the choice of the optimal therapeutic method.

Corresponding author: Mircea-Sebastian Serbanescu, Lecturer, MD, PhD; e-mail: mircea_serbanescu@yahoo.com

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22. Death-causing cardiac injuries after chronic alcohol intake identified by forensic medicine

Dragos-Valentin Crauciuc, Cristinel Ionel Stan, Laura Adriana Riscanu, Daniel-Cristian Pirvu, Diana Bulgaru-Iliescu

Ethyl alcohol is the most consumed drug, worldwide, with frequent consequences on the individual s health and lifestyle. Chronic alcoholism is a pathological state occurring after an excessive alcohol intake and may be observed in teenagers or very old individuals. The study performed by us investigated the changes caused by alcohol intake in the left ventricle myocardium in 77 bodies deceased at home under suspect circumstances and sent to the Institute of Forensic Medicine for establishing the cause of death. In all the individuals, there was determined high levels of blood Ethyl glucuronide, thus showing the alcohol intake up to 96 hours before death. The lesions present in the heart were represented by dilated cardiomyopathy, myocardial fibrosis, and myocardial infarction.

Corresponding author: Dragos-Valentin Crauciuc, Assistant, MD; e-mail: crauciuc.dragos@gmail.com; Daniel-Cristian Pirvu, Assistant, MD, PhD; e-mail: pirvu_daniel2005@yahoo.com

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23. Cardiofaciocutaneous syndrome - a longitudinal study of a case over 33 years: case report and review of the literature

Maria Claudia Jurca, Oana Alexandra Iuhas, Maria Puiu, Adela Chirita-Emandi, Nicoleta Ioana Andreescu, Codruta Diana Petchesi, Alexandru Daniel Jurca, Ioan Magyar, Sanziana Iulia Jurca, Kinga Kozma, Emilia Maria Severin, Marius Bembea

Cardiofaciocutaneous (CFC) syndrome [Online Mendelian Inheritance in Man (OMIM) 115150] is characterized by craniofacial dysmorphism, heart malformation, ectodermal abnormalities, neuromotor delay and intellectual disability. It is not a frequent disease, about 300 cases have been reported in the medical literature. We describe the case of a 34-year-old patient presenting with CFC syndrome phenotype, monitored since the age of 1 1/2 years. Clinical findings included craniofacial dysmorphism, development delay, heart malformation and severe intellectual disability. The evolution was with progressive intellectual disability, hypogonadism, hypertrophic cardiomyopathy, wrinkled palms and soles. Molecular analysis showed a heterozygous variant in the B-Raf proto-oncogene, serine/threonine kinase (BRAF) gene (7q34): NM_001354609.2:c.1502A>G, with pathogenic significance. We report this case, observed along a period of 33 years, for illustration of clinical evolutive particularities, and for difficulties in establishing the positive diagnosis.

Corresponding author: Alexandru Daniel Jurca, Lecturer, MD, PhD; e-mail: alexjurca@yahoo.co.uk; Codruta Diana Petchesi, Assistant Professor, MD, PhD Student; e-mail: petchesi_diana@yahoo.com

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24. An extremely uncommon case of pancreatic extragastrointestinal stromal tumor in a 53-year-old female patient

Dragos Ene, Lucian Mihai Florescu, Razvan Ene, Bogdan Popescu, Ioana Andreea Gheonea

Gastrointestinal stromal tumors (GISTs) are the most frequently encountered mesenchymal tumors that develop anywhere along the gastrointestinal (GI) tract, but they account for less than 1% of all GI tumors. However, GISTs can also develop outside the GI tract. They are referred to as extragastrointestinal stromal tumors (EGISTs) and represent around 5-10% of all GISTs. In this latter case, the tumor itself is not connected to the GI tract and can affect the omentum, mesentery, and retroperitoneum. EGISTs can also originate from the pancreas, but they are extremely uncommon. It is estimated that pancreatic EGISTs account for about 5% of all EGISTs, with around 30 cases being reported in the literature so far. The current report presents an extremely rare case of pancreatic EGIST encountered in a 53-year-old woman with no remarkable personal or family medical history. Surgical resection of the pancreatic head tumor through pancreaticoduodenectomy using Whipple procedure combined with negative resection margins and adjuvant Imatinib mesylate treatment led to a favorable postoperative evolution. The follow-up at six months after surgery did not reveal any malignant changes.

Corresponding author: Lucian Mihai Florescu, MD, PhD; e-mail: lucian.florescu@umfcv.ro; Razvan Ene, MD, PhD; e-mail: razvan77ene@yahoo.com

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25. Neck synovial sarcoma: case presentation

Konstantinos Sapalidis, Stiliani Laskou, Vasiliki Manaki, Vasiliki Magra, Stelian Pantea, Theodora Gkeka, Carmen Aurelia Mogoanta, Daniel-Cristian Pirvu, Isaak Kesisoglou

Head and neck synovial sarcoma (HNSS) is a rare tumor with a few case reports or case series being published in the literature. We present the case of a 68-year-old patient admitted to our department for management of a palpable neck mass. After initial investigation and due to major problems of differential diagnosis, there was performed a wide excision of the tumor. Histopathology examination revealed an HNSS.

Corresponding author: Konstantinos Sapalidis, Associate Professor of Surgery, MD, PhD; e-mail: sapalidiskonstantinos@gmail.com; Daniel-Cristian Pirvu, Assistant, MD, PhD; e-mail: daniel.pirvu@umfcv.ro

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26. Peripheral-type primitive neuroectodermal tumor of the ovary with EWSR1-FLI1 fusion transcript: a case report and brief review of literature

Corina Grigoriu, Dana Cristina Terzea, Antonia Carmen Lisievici, Tiberiu Augustin Georgescu, Andreea Elena Constantin, Nicolae Bacalbasa, Ionita Ducu, Roxana Elena Bohiltea

Primitive neuroectodermal tumors (PNETs) of the ovary are extremely rare tumors composed of undifferentiated small cells with round nuclei and scant cytoplasm. They are rare in general and extremely rare in the female gynecological tract, where they most commonly affect the ovary, followed by the uterine corpus. The most common presenting symptoms are abdominal pain, bloating and the presence of a pelvic mass. Diagnosis mainly relies on immunohistochemical and fluorescence in situ hybridization (FISH). Due to the rarity of these tumors, there are no standard therapeutic guidelines and treatment consists of surgery, various chemotherapy regimens and/or radiotherapy. In this article, we report the case of a 30-year-old female with peripheral-type PNET (pPNET) of the ovary featuring Ewing sarcoma breakpoint region 1-Friend leukemia integration 1 (EWSR1-FLI1) fusion transcript, confirmed by next-generation sequencing (NGS).

Corresponding author: Antonia Carmen Lisievici, Assistant Professor, MD, PhD; e-mail: lisievici.carmen@yahoo.com; Tiberiu Augustin Georgescu, Assistant Professor, MD, PhD; e-mail: tiberiuaugustin.georgescu@gmail.com

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27. A rare case of intrathoracic fetus in fetu / mature teratoma - pathological and imagistic aspects

Alin Dragos Demetrian, Alexandra Floriana Nemes, Adrian Macovei, Camelia Demetrian, Dana Maria Albulescu, Cristian Constantin

Fetus in fetu (FIF) is a rare entity, with a difficult preoperative diagnosis, frequently being an intraoperative surprise. In recent literature, theories pertaining to its development either assimilate the tumor with a monochorionic twin that halted its evolution, or with a highly differentiated mature teratoma. We present the case of a 27-year-old patient, with a cystic tumor in the anterior mediastinum, which intraoperatively proved to be a rare case of intrathoracic FIF. The clinical presentation lacked any specific clues that would infer such a diagnosis; imaging was partially useful as it shown the possible existence of bone structures, heterogeneously mixed with fatty inclusions and other types of tissue. Upon surgery, the nature of said tumor was clear, and pathology confirmed the FIF diagnosis, showing different types of epithelia and tissue of several organ-like structures that halted in evolution at an early stage. Concluding our presentation, we can say that the presence of an axial skeleton as well as differentiated tissue types of several organs could confirm our case of FIF.

Corresponding author: Dana Maria Albulescu, MD, PhD; e-mail: med73danam@yahoo.com; Adrian Macovei, Teaching Assistant, MD, PhD; e-mail: adrian.macovei@gmail.com

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28. Supernumerary permanent maxillary canine - a rare finding: case report and literature review

Oana-Cella Andrei, Mirela Ileana Dinescu, Catalina Farcasiu, Adriana Bisoc, Daniela Ioana Tarlungeanu, Livia Alice Tanasescu, Magdalena Natalia Dina, Mihai Burlibasa, Ruxandra Margarit

Supernumerary teeth are dental units that appear in addition to the regular number of teeth. Their most frequent location is the anterior maxilla, especially on the maxillary midline, being called mesiodens, but also paramedian or in the position of a lateral incisor. On the other hand, the permanent canine is one of the most stable teeth regarding the number, with very few cases reported about hypo- or hyperdontia. This article reviews the few data found in the literature about the supernumerary permanent maxillary canine and also presents the case of an 8-year-old female patient with a supplemental permanent canine in the upper left maxilla. The patient was non-syndromic and did not present any other supernumerary teeth in the permanent dentition; she had only one in the temporary dentition. Using cone-beam computed tomography (CBCT) of the region, we were able to evaluate the position, structure, and shape of the supplemental canine and also to establish a treatment plan. The aim of this paper was to present this extremely rare case of a non-syndromic Romanian adult female patient with a unilateral supplemental permanent maxillary canine, and to include a literature review of the few reported such cases.

Corresponding author: Catalina Farcasiu, Assistant Professor, DMD, PhD; e-mail: catalina.farcasiu@yahoo.com; Adriana Bisoc, Assistant Professor, DMD, PhD; e-mail: adry_bis@yahoo.com

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29. Bimalleolar pathological fracture in a patient with chronic tophaceous gout

Laszlo Irsay, Danut-Georgel Perja, Kamal Constantin Kamal, Magdalena Rodica Traistaru, Diana Kamal, Viorela Mihaela Ciortea, Theodor Popa, Ileana Monica Borda, Rodica Ana Ungur, Alina Deniza Ciubean

Gout is one of the most common types of inflammatory arthritis. Four stages have been described in its evolution: asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout and chronic tophaceous gout. Monosodium urate crystals deposits are more frequently encountered in hyaline cartilage, tendon sheaths, articular bursae, bone epiphysis, synovium, and skin. Pathological fractures that occur at the formation sites of gout tophi have been rarely described in gout. Bimalleolar fractures often occur following a trauma. We present the case of a 56-year-old patient, diagnosed with chronic gout for over 12 years, with tophi in the upper and lower limbs, who presented accusing mechanical pain in the left tibio-tarsal joint and impaired function of the hands. The clinical examination showed bilateral multiple destructive gout tophi in the hands, forearms, elbows, feet, ankles, and lower legs, while the left ankle exhibited an important varus deformity. Computed tomography examination of the left ankle showed multiple gout tophi with bone erosions and a bimalleolar pathological fracture. The patient underwent pharmacological treatment, physical therapy and the ankle was immobilized in a knee-ankle-foot orthosis, with subsequent orthopedic surgical treatment for fracture fixation, to improve functional status. We have chosen to present this case given the multiple disabilities of the patient, which have improved following the rehabilitation treatment.

Corresponding author: Viorela Mihaela Ciortea, MD, PhD; e-mail: viorela.ciortea@yahoo.com; Kamal Constantin Kamal, Assistant Professor, MD, PhD, MSc; e-mail: kamalconstantin@gmail.com

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30. Conventional grade 1 chondrosarcoma: a challenging diagnosis with important implications on therapy and prognosis

Gabriel Veniamin Cozma, Laurentiu Vasile Sima, Raluca Maria Closca, Flavia Baderca, Ioana Delia Horhat, Nicolae Constantin Balica, Alina Andreea Tischer, Ion Cristian Mot, Daniel Claudiu Malita, Aurel Marin, Cristian Andrei Sarau

Chondrosarcoma (CHS) is a malignant tumor of soft tissue with cartilaginous differentiation that represent one tenth of all malignant proliferations developed from bone tissues. Even if CHS represents the third malignancy with bone localization, after myeloma and osteosarcoma, it is far less diagnosed in the head and neck region. The current paper presented two cases of conventional CHSs, which were diagnosed in Department of Thoracic Surgery and Department of Otorhinolaryngology of Emergency City Hospital, Timisoara, Romania, between February and June 2021. The malignant cases were of peripheral CHSs, one of scapula, and the other one had an extremely rare tracheal location with microscopic features of conventional low-grade tumors (grade 1). In all cases, conservative surgical curative treatment was performed, with a favorable postoperative evolution.

Corresponding author: Ioana Delia Horhat, Assistant Professor, MD, PhD; e-mail: deliahorhat@yahoo.com; Alina Andreea Tischer, MD, PhD; e-mail: flaviabaderca@gmail.com

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31. Staphylococcus aureus-induced septic arthritis of the ankle related to malum perforans in a diabetes patient

Stefan Cristian Dinescu, Andreea Lili Barbulescu, Sineta Cristina Firulescu, Andreea Beatrice Chisalau, Cristina Dorina Parvanescu, Paulina Lucia Ciurea, Raluca Elena Sandu, Adina Turcu-Stiolica, Mihail Virgil Boldeanu, Elena Madalina Vintila, Florin Liviu Gherghina, Ananu Florentin Vreju

Septic arthritis (SA) is a less common joint pathology with potentially fatal outcome. It is considered a medical emergency, in which prompt diagnosis and differentiation of bacterial etiology is essential for appropriate management. The knee is the most prevalent site for SA (cca. 50% of cases), followed by hip, shoulder, and elbow. Early intervention requires an accurate diagnosis and imaging techniques enable both a positive diagnosis, as well as arthrocentesis and liquid analysis, the gold standard criteria. We report the case of a 70-year-old patient, with history of rheumatoid arthritis (RA), diabetes mellitus (DM) and persistent left malum perforans in the last year, with development of a severe and debilitating Staphylococcus aureus-related SA of the left ankle, which posed significant therapeutic challenges. He developed a plantar lesion at the ball of the left foot, in the past one year, which was labeled as malum perforans in the setting of DM. Musculoskeletal ultrasound was the primary imaging technique used to define the location and extent of the infectious process. Cultures drawn from the tissue were positive for S. aureus. After an antibiotic course, the apparent infectious features were remitted but the long-lasting open wound failed to improve. Antibiotic therapy was initiated in accordance with culture sensibility tests but short- and long-term outcome was unfavorable with both treatment unresponsiveness and comorbidity burden posing considerable difficulties. The association and interrelation between different comorbidities (such as hypertension, diabetes, or obesity), chronic systemic inflammation (e.g., C-reactive protein level, disease activity), and RA medication is sometimes difficult to understand and to address in daily practice, and this case report highlights multiple toils encountered in a SA patient with RA on immunosuppressive therapy and complicated DM.

Corresponding author: Mihail Virgil Boldeanu, Lecturer, MD, PhD; e-mails: laborator.imunologie@umfcv.ro, boldeanumihailvirgil@yahoo.com; Adina Turcu-Stiolica, Associate Professor, MD, PhD; e-mail: adina.turcu@gmail.com

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32. Eosinophilic sialodochitis: a case report of a rare disease

Octavian Marius Dinca, Andreea Cristiana Didilescu, George Cristian Vladan, Mihai Bogdan Bucur, Lavinia Cristina Padurariu, Alexandru Bucur

Eosinophilic sialodochitis (ES) is a rare clinical entity which presents as recurrent major salivary gland swelling and the presence of eosinophil-rich mucus plugs or histopathological evidence of eosinophilic infiltration around the larger salivary gland ducts. We present a case of ES not related with underwent a left submaxillectomy because recurrent episodes of submandibular gland swelling associated for the last three years. The laboratory workup demonstrated eosinophils slightly elevated and high levels of immunoglobulin E (IgE) in peripheral blood. Pathology slides confirmed the final diagnosis of ES, showing a dense periductal eosinophil-rich inflammatory infiltrate and periductal fibrosis. Although the entity is well described in the literature, diagnosis is often difficult due to its clinical presentation being similar to other conditions. Lesions that should be taken into consideration in differential diagnosis are mentioned. This will be the first ES case report in Eastern European literature.

Corresponding author: George Cristian Vladan, Lecturer, MD, PhD; e-mail: cristi.vladan@umfcd.ro; Andreea Cristiana Didilescu, Professor, DDS, MPhil, MSc, PhD; e-mail: andreea.didilescu@umfcd.ro

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33. A rare case of transmigrated mandibular canine and combined orthodontic-surgical management

Catalina Farcasiu, Mirela Ileana Dinescu, Daniela Ioana Tarlungeanu, Marilena Bataiosu, Constantin Daguci, Luminita Daguci, Magdalena Natalia Dina, Oana-Cella Andrei

Canines are paramount teeth for esthetics and function. Transmigration of the lower permanent canine is a rare process of alteration of the eruption path toward the opposite part of the mandible. The position of the migrating tooth varies at different ages, so early detection of the tendency to cross the midline is crucial; canines that have already passed through the center of the mandible can be impossible to realign. Transmigration can start any time before the normal age of eruption. Comparing two radiographic images taken at different ages offers important diagnosis information. Camilleri and Scerri (2003) described a progressive alteration of the tooth position in four steps, from the normal appearance to a low position inside the corpus of the mandible. Following this classification, this article s aim was to present a case of an impacted lower canine that was diagnosed between the second and third stage of transmigration, around the age of 10, and to detail the combined orthodontic-surgical treatment strategy for recapturing and the orthodontic mechanics used to align it. After the examination of cone-beam computed tomography, we have decided to use a lingual arch as a space maintainer and anchorage tool and to surgically expose the tooth. The canine s initial position and the direction of the force of traction used allowed a proper alignment of the tooth inside the dental arch. The periodontal tissues management was important for good healing, stability, and aesthetics. The early detection allowed a proper interdisciplinary orthodontic-surgical management, and a successful outcome.

Corresponding author: Luminita Daguci, Associate Professor, DMD, PhD; e-mail: daguciluminita@yahoo.com; Constantin Daguci, Associate Professor, DMD, PhD; e-mail: dagucicristi@yahoo.com

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34. Bifid mandibular canal - a case report

Vlad Ionut Iliescu, Suzana Carmen Cismas, Ramona Ionela Truta, Ovidiu Romulus Gherghita, Victor Nimigean, Vanda Roxana Nimigean

One of the most common anatomical variations of the mandibular canal is the bifid mandibular canal (BMC), more frequently unilateral and rarely bilateral, often located at the level of the posterior mandible; according to literature, this anatomical variation presents several morphological types. The presence of the BMC must be considered prior to anesthesia and surgery performed on the ramus of the mandible (osteotomies) and on the posterior mandible (dentoalveolar surgery procedures). This study presents a clinical case of unilateral BMC on the left side, the buccolingual type, lingual variant, a rare anatomical variation illustrated radiographically in a 27-year-old male adult.

Corresponding author: Victor Nimigean, Professor, DMD, MD, PhD; e-mail: victornimigean@yahoo.com

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