ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 63 No. 1, January-March 2022

1. Short histological kaleidoscope - recent findings in histology. Part I

Anne-Marie Constantin, Carmen Mihaela Mihu, Adina Bianca Bosca, Carmen Stanca Melincovici, Mariana Viorica Marginean, Elena Mihaela Jianu, Roxana Adelina Stefan, Bogdan-Catalin Alexandru, Ioana Maria Moldovan, Alina Simona Sovrea, Rada Teodora Sufletel

This article is a review of new advances in histology, concerning either classification or structure of different tissular elements (basement membrane, hemidesmosomes, urothelium, glandular epithelia, adipose tissue, astrocytes), and various organs constituents (blood-brain barrier, human dental cementum, tubarial salivary glands, hepatic stellate cells, pineal gland, fibroblasts of renal interstitium, Leydig testicular cells, ovarian hilar cells), as well as novel biotechnological techniques (tissue engineering in angiogenesis), recently introduced.

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

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2. Liquid biopsy in lung cancer management

Maria-Anca Irofei Zamfir, Laura Buburuzan, Ariana Hudita, Bianca Galateanu, Octav Ginghina, Daniel Ion, Natalia Motas, Carmen Maria Ardeleanu, Marieta Costache

Liquid biopsy is a promising tool for a better cancer management and currently opens perspectives for several clinical applications, such as detection of mutations when the analysis from tissue is not available, monitoring tumor mutational burden and prediction of targeted therapy response. These characteristics validate liquid biopsy analysis as a strong cancer biomarkers source with high potential for improving cancer patient s evolution. Compared to classical biopsy, liquid biopsy is a minimal invasive procedure, and it allows the real-time monitoring of treatment response. Considering that lung cancer is the most common cause of cancer-associated death worldwide and that only 15-19% of the lung cancer patients survive five years after diagnosis, there is an important interest in improving its management. Like in other types of solid cancers, lung cancer could benefit from liquid biopsy through a simple peripheral blood sample as tumor-related biomarkers, such as circulating tumor cells (CTCs), cell-free nucleic acids (cfNA) [cell-free ribonucleic acid (cfRNA) and cell-free deoxyribonucleic acid (cfDNA)], exosomes and tumor-educated platelets (TEPs) may shed into circulation because of necrosis or in an active manner. More, the detection and analysis of these biomarkers could lead to a better understanding of oncological diseases like lung cancer. The better the tumor profile is established; the better management is possible. However, this approach has currently some limitations, such as low cfNA concentration or low count of CTCs that might be overcome by improving the actual methods and technologies.

Corresponding author: Natalia Motas, MD, PhD; e-mail: natalia.motas@gmail.com

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3. COVID-19 infection: from stress-related cortisol levels to adrenal glands infarction

Mihaela Popescu, Dana Cristina Terzea, Mara Carsote, Alice Elena Ghenea, Andrei Costache, Iulian Alin Silviu Popescu, Viorel Biciusca, Cristina Jana Busuioc, Adina Mariana Ghemigian

Cortisol is a key element in acute stress including a severe infection. However, in coronavirus-associated disease, 20% of subjects experience hypocortisolemia due to direct or immune damage of pituitary and adrenal glands. One extreme form of adrenal insufficiency is found in 2/3 of cases with viral and post-viral adrenal infarction (AI) (with/without adrenal hemorrhage) that is mostly associated with a severe coronavirus disease 2019 (COVID-19) infection; it requires prompt glucocorticoid intervention. Some reports are incidental findings at computed tomography (CT)/magnetic resonance imaging (MRI) scans for non-adrenal complications like pulmonary spreading and others are seen on post-mortem analysis. This is a review of PubMed-accessible, English papers focusing on AI in addition to the infection, between March 1, 2020 and November 1, 2021. Exclusion criteria were acute adrenal insufficiency without the histopathological (HP) and/or imaging report of adrenal enlargement, necrosis, etc., respective adrenal failure due to pituitary causes, or non-COVID-19-related adrenal events. We identified a total of 84 patients (different levels of statistical evidence), as follows: a retrospective study on 51 individuals, two post-mortem studies comprising nine, respectively 12 patients, a case series of five subjects, seven single-case reports. HP aspects include necrosis associated with ischemia, cortical lipid degeneration (+/- focal adrenalitis), and infarcts at the level of adrenal cortex, blood clot into vessels, acute fibrinoid necrosis in arterioles and capsules, as well as subendothelial vacuolization. Collateral potential contributors to adrenal damage are thrombotic events, coagulation anomalies, antiphospholipid syndrome, endothelial dysfunction, severe COVID-19 infection with multiorgan failure, etc. Clinical picture is variable from acute primary adrenal insufficiency to asymptomatic or mild evolution, even a retrospective diagnostic; it may be a part of long COVID-19 syndrome; glucocorticoid therapy for non-adrenal considerations might mask cortisol deficient status due to AI/hemorrhage. Despite its rarity, the COVID-19-associated AI/hemorrhage represents a challenging new chapter, a condition that is essential to be recognized due to its gravity since prompt intervention with glucocorticoid replacement is lifesaving.

Corresponding author: Mara Carsote, MD, PhD, Senior Lecturer of Endocrinology; e-mail: carsote_m@hotmail.com

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4. Isolated hypoplastic right ventricle - a challenge in medical practice

Eliza Elena Cinteza, Alin Marcel Nicolescu, Mihaela Adela Iancu, Gabriela Ganea, Matei Dumitru, Gheorghe Gindrovel Dumitra

Isolated right ventricle hypoplasia (IRVH) is a disease characterized by an underdeveloped right ventricle. It is a congenital heart disease than can associate heterogeneous structural defects and nonspecific clinical features, which can often present a challenging therapeutic management. In this article, there are presented diagnostic methods and treatment options for right ventricle hypoplasia (RVH) according to clinical features, patients age and associated structural heart defects. RVH has a different prognosis in accordance with the severity of the heart defects and the patient s age at which the diagnosis is established. Thus, isolated forms of RVH generally present mild structural and functional defects that can be associated with the onset of symptoms in adolescence or even in adulthood. In these cases, atrial septal defect closure with or without superior cavo-pulmonary anastomosis can be the only procedures needed to correct the hemodynamic abnormalities and relief the symptomatology. Patients with severe form of RVH associated with complex cardiac malformations and onset of the symptoms in the neonatal period require prompt intervention and necessitate palliative procedures. In the long term, these patients could need multiple reinterventions. The family physician should be aware of the cardiac origin of isolated symptoms or clinical signs, such as exertional dyspnea or clubbing fingers, and send the patient for pediatric cardiological evaluation.

Corresponding author: Mihaela Adela Iancu, Associate Professor, MD, PhD; e-mail: adela.iancu@umfcd.ro

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5. Implications at the ocular level of miRNAs modifications induced by SARS-CoV-2 infection

Adina-Iuliana Milcu, Andrei Anghel, Ovidiu Musat, Mihnea Munteanu, Madalina-Casiana Salavat, Andreea Iordache, Emil Ungureanu, Diana Camelia Bonte, Ovidiu Boruga

The coronavirus disease 2019 (COVID-19) pandemic determined the use of different research methods and investigations in the management of this novel infectious disease. The impact and development of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at cellular level is still a challenge and many directions of investigation have been opened, a complex topic that has been explored is the bidirectional interaction between host micro-ribonucleic acids (miRNAs) and viral miRNA. The main point of this study is to analyze the transcriptional modifications induced by the viral infection at ocular level, mediated by miRNAs. It is known that the ocular transmission is a route of infection, and it can cause multiple neuro-ophthalmological manifestations, such as optic nerve dysfunction, eye movement abnormalities, oscillopsia and intracranial hypertension. We have managed to identify more than six miRNAs specifically involved in eye disorders that are strongly dysregulated by the SARS-CoV-2. These miRNAs regulate different pathways, such as the nuclear factor-kappa B (NF-kappaB) pathway, the expression of complement factor H (CFH) gene, the expression of transforming growth factor-beta (TGF-beta), fibroblast growth factor (FGF) and platelet-derived growth factor (PDGF) genes. In the context of SARS-CoV-2 infection, many more molecular changes at ocular level need to be elucidated to better understanding the COVID-19.

Corresponding author: Andrei Anghel, Professor, PhD; e-mail: biochim@umft.ro; Ovidiu Musat, MD, PhD; e-mail: ovidiumusat@yahoo.com

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6. Degenerative bony changes in the temporal component of the temporomandibular joint - review of the literature

Maria Justina Roxana Virlan, Daniela Elena Costea, Diana Loreta Paun, Adina Zamfir-Chiru-Anton, Alin Gabriel Sterian, Arsenie Dan Spinu, Victor Nimigean, Vanda Roxana Nimigean

Temporomandibular joint (TMJ) changes are quite frequent in adults, but not all changes are degenerative. A high prevalence of bone alterations in the TMJs was reported by different research groups. Disturbed remodeling of bony articulating structures occurs because of overloading masticatory forces or because the mechanical loading in the area out-weighs the adaptive capacity of the TMJ structures. Although most of the degenerative TMJ alterations are identified at the level of the condylar process, a complete evaluation of the degenerative modifications encountered in the temporal TMJ region should not be forgotten as they are important for a comprehensive assessment and further management of the clinical situation. Several research groups have described osseous remodeling in the temporal component of the TMJ. Evidence is scarce for degenerative modifications at the level of the articular eminence and thickening of the roof of the glenoid fossa has been associated with osteoarthritis.

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

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7. Remodeling of the aortic wall layers with ageing

Mirela Albu, Doru Adrian Seicaru, Razvan Mihail Plesea, Oana Cristina Mirea, Florentina Gherghiceanu, Valentin Titus Grigorean, Mircea-Sebastian Serbanescu, Iancu Emil Plesea, Mircea Litescu

Aim: The authors aimed to evaluate the correlations between the variation of two of the main morphological parameters of the aortic wall (intima and media thicknesses) and ageing. Materials and Methods: Aortic cross sections (base region, cross region, thoracic region, and abdominal region) were collected from 90 cases of all ages died and autopsied in the hospital. Tissue samples were processed using the classical histopathological technique (formalin fixation and paraffin embedding) and stained with Orcein and Goldner s trichrome. The obtained histological slides were transformed into virtual slides. Intima and media thicknesses were determined on virtual slides using a custom-made software, developed in MATLAB (MathWorks, USA). Results and Discussions: The intima layer underwent an obvious and continuous process of thickening both from the aortic base region to its terminal (abdominal) region and from young ages to old age. The processes were similar in men and women but almost always more pronounced in men than in women. The media layer underwent a thickness reduction process from the aortic base to the terminal (abdominal) region whereas with age, the thickness of the layer increased. This divergent profile of evolution was similar in both men and women but with some variations depending on either topography or ageing. Conclusions: Each of the main layers of the aortic wall revealed dynamic individual evolutionary profiles related to age, gender and topography along the aortic path. Studies must be continued in a more detailed, standardized and integrated way.

Corresponding author: Iancu Emil Plesea, Professor, MD, PhD; e-mail: emil.plesea@umfcd.ro

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8. Maternal alloxan exposure induces damage in rat offspring lumbar vertebrae and protective role of arachidonic acid

Ayman Salaheldeen Amer, Refaat Shehata Mohamed, Ashraf Edward Bastwrous, Martha Emil Adly

Background: Vertebral abnormalities in offspring of diabetic mothers make major challenges worldwide and were not sufficiently studied before. Aim: To investigate the effects of alloxan-induced diabetes on rats lumbar vertebrae, and to assess the potential beneficial impact of arachidonic acid. Materials and Methods: Pregnant rats were randomly equally divided into four groups: control, alloxan-induced diabetes received alloxan injection 150 mg/kg, alloxan + arachidonic acid group received arachidonic acid 10 micro-g/animal then given alloxan injection, and arachidonic acid group received it, until offspring age of three weeks. Six male offspring from each group were included in this study at ages of newborn, three-week-old, two-month-old, and their body measurements were recorded. Lumbar vertebrae and pancreas specimens were examined by light microscopy, morphometry, transmission electron microscopy (TEM), and immunohistochemistry for insulin expression. Results: In alloxan-induced diabetes newborn, three-week-old, and two-month-old rats, body measurements were significantly declined, histomorphometry of 6th lumbar vertebrae revealed disorganized chondrocytes, with vacuolated cytoplasm, empty lacunae, diminished matrix staining, with areas devoid of cells. TEM showed shrunken reserve and proliferative cells, with irregular nuclei, and damaged mitochondria. In contrast, alloxan + arachidonic acid group had cytoarchitecture of lumbar vertebrae that were like control group. Histomorphometry of pancreas in alloxan-induced diabetes group showed significant reduction in pancreatic islets number and surface area, damaged pancreatic islet cells appeared atrophied with apoptotic nuclei, and very weak insulin immunostaining. Whereas alloxan + arachidonic acid group displayed healthy features of pancreatic islets, which resembled control group, with strong insulin immunostaining. Conclusions: Arachidonic acid mitigated alloxan-induced diabetes by its antidiabetic activity.

Corresponding author: Ayman Salaheldeen Amer, Professor, PhD; e-mail: ayman.amer@aun.edu.eg

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9. Maternal obesity and placental pathology in correlation with adverse pregnancy outcome

Maria Carmen Tabacu, Anca-Maria Istrate-Ofiteru, Maria Magdalena Manolea, Anda Lorena Dijmarescu, Luciana Teodora Rotaru, Mihail Virgil Boldeanu, Mircea-Sebastian Serbanescu, Adriana Tudor, Marius Bogdan Novac

Maternal obesity is associated with increased maternal and fetal morbidity and mortality, with an increased risk of gestational diabetes mellitus (GDM) and preeclampsia (PE). This prospective study histopathologically analyzes the placentas obtained from 34 pregnant obese women studied between October 2016 and May 2020. The 10 cases of term placentas from obese pregnancies with GDM and the 12 cases with PE were examined by the Hematoxylin-Eosin (HE), Masson s trichrome (MT) and Periodic Acid-Schiff-Hematoxylin (PAS-H) classical stainings, and by the immunohistochemical evaluation and compared to placentae from uncomplicated term obese pregnancies (12 cases). We did not meet placental histopathological (HP) abnormalities that we could classify as characteristic only for the state of obese pregnancy, but we did find placental changes associated with PE and GDM, in the context of obese pregnancy. In the case of association with PE, there were common lesions, manifested by intra- and perivillous fibrinoid deposition, calcification, and placental infarction area, to which were added numerous syncytial knots. In the case of obese pregnancy associated with GDM, we found, in addition to common placental lesions of obesity, intravillositary vascular edema and in the terminal villi appearing chorangiosis. This study revealed a number of HP changes that occur in maternal obesity, even in uncomplicated obese pregnancies. A characteristic of obese pregnancies associated with PE was the presence of numerous syncytial knots, and in obese pregnancies associated with GDM, the most common HP lesion was placental chorangiosis. Certainly, we cannot conclude that these HP lesions are specific to a particular pathology, but they belong primarily to the status of maternal obesity.

Corresponding author: Maria Magdalena Manolea, Lecturer, MD, PhD; e-mail: magdalena.manolea@umfcv.ro; Mihail Virgil Boldeanu, Associate Professor, MD, PhD; e-mail: boldeanumihailvirgil@yahoo.com, mihail.boldeanu@umfcv.ro

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10. Current approach of juvenile nasopharyngeal angiofibroma: a case series

Andreea Nicoleta Vlaescu, Elena Ionita, Mircea Sorin Ciolofan, Carmen Aurelia Mogoanta, Catalina Voiosu, Andreea Rusescu, Razvan Hainarosie

Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign tumor that affects predominantly males and is known by its highly vascular character. We have performed a 3-year retrospective study of patients with JNA surgically treated within the third ENT Department of Prof. Dr. Dorin Hociota Institute of Phonoaudiology and Functional ENT Surgery, Bucharest, Romania. In all the cases, the patients were investigated both clinically and through medical imaging before surgery and all tumors were embolized. Our study comprised of eight cases, of which seven were solved by endoscopic endonasal approach and one case was treated through a combined endonasal-external approach. JNA should always be managed through a multidisciplinary team (MDT) approach in centers with adequate experience, to gain favorable results.

Corresponding author: Mircea Sorin Ciolofan, Senior Lecturer, MD, PhD; e-mail: sorin.ciolofan@yahoo.com; Andreea Rusescu, Assistant, MD, PhD; e-mail: andreearusescu@gmail.com

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11. The analysis of hormonal status and vascular and cell proliferation in endometrioid endometrial adenocarcinomas

Ileana Drocas, Stefania Craitoiu, Alex Emilian Stepan, Dominic Gabriel Iliescu, Ioan Andrei Drocas, Mioara Desdemona Stepan

Endometrioid endometrial carcinomas (EECs) are the most common malignancies of the uterus. Hormonal dependence of EEC, in relation to biomolecular mechanisms involved in tumor progression, such as angiogenesis and cell proliferation, are aspects that can contribute to improving the prognosis of patients. We analyzed the immunoexpression of markers addressed to steroid hormone receptors [estrogen receptor (ER), progesterone receptor (PR)], angiogenesis [cluster of differentiation (CD)105/endoglin] and cell proliferation (Ki-67) in 50 EECs related to the histopathological prognostic criteria of the lesions. In this study, the ER and PR scores were higher in low grade and early stages EEC, the statistical aspects being variable. The CD105 microvessel density and the Ki-67 proliferation index were superior in high grade and advanced stages EEC, the statistical aspects being significant or at the limit of significance. The ER/PR and CD105/Ki-67 immunomarker groups indicated a positive linear intragroup relation and a negative linear intergroup relation, suggesting the presence of synergistic and antagonistic molecular mechanisms of tumor endometrial control that can be used to stratify patients for targeted therapy.

Corresponding author: Alex Emilian Stepan, Professor, MD, PhD; e-mail: astepan76@yahoo.com; Ioan Andrei Drocas, Teaching Assistant, MD, PhD; e-mail: andrei_drocas@yahoo.com

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12. Benefits of genetic and immunohistochemical markers in understanding abnormalities in aging retina

Delia-Maria Ormenisan, Angela Borda

The aim of the study was to better understand the interplay between genetic factors and the aging process in the human retina through mapping complement factor H (CFH) and related proteins. Two human eyes, from 92- and 64-year-old donors, were genotyped for the expression of CFH-related 1 (CFHR1) and CFH-related 3 (CFHR3) genes. Deoxyribonucleic acid (DNA) was extracted and analyzed for concentration and purity with a spectrophotometer, at 260 nm. The results showed a DNA concentration of 469.17 ng/micro-L in the aged retina and of 399.20 ng/micro-L in the younger one. Through polymerase chain reaction (PCR) genotyping, the DNA CFHR1 and CFHR3 were visible as bands of 175 bp and 181 bp. Immunohistochemistry by immunofluorescence method was used with a panel of specific antibodies for CFH, CFHR1, CFHR3 and GFAP, a marker for Muller cells. All the samples were examined, and images captured using confocal microscopy. In the younger retina, CFH was localized in the inner plexiform layer and below the outer nuclear layer, while in the aged retina, it was found in the photoreceptors. CFH was also detected in the choriocapillaris and within the end-feet of the Muller cells. Our controls showed autofluorescence of the retinal pigment epithelium shedding light on a false positive CFH immunostaining of this layer. GFAP immunoreactivity highlighted an increased gliosis within the aged retina. CFHR3 signal was found in the microglia, while CFHR1 was detected in the choriocapillaris. In summary, underpinning the expression of these components can show the potential involvement of these modulators in implementing new treatment strategies.

Corresponding author: Delia-Maria Ormenisan, MD; e-mail: delia.ceteras@gmail.com

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13. Mast cell density in the primary tumor predicts lymph node metastases in patients with breast cancer

Erwin Floroni, Amalia Raluca Ceausu, Raluca Mioara Cosoroaba, Ioana Cristina Niculescu Talpos, Ramona Amina Popovici, Nela Pusa Gaje, Marius Raica

Breast cancer (BrCa) is the most frequent neoplastic disease in female, with high morbidity and mortality. Most of the researches were focused on tumor cells concerning their natural evolution, molecular profile, and potential response to therapy. Few and uncertain data are available about the tumor microenvironment and its impact on the progression of the disease. Mast cells (MCs) associated to BrCa have been reported many years ago, but their real and specific role in the biology of this disease remained elusive. In the current study, we have investigated the predictive role of MCs from the primary tumor on lymph node metastasis on patients stratified based on the molecular classification. We investigated 156 patients with BrCa, stratified as luminal A, luminal B, human epidermal growth factor receptor 2 (HER2) type, basal-like, and unclassified. MCs were identified with anti-MC tryptase antibody in a double immunohistochemical reaction combined with anti-cluster of differentiation 34 (CD34) antibody. Mast cell density (MCD) was calculated based on the hot-spot method, on three fields with maximum density of MCs in each case. The final result was the arithmetic media that was compared with the molecular profile and lymph node metastases. We found no significant correlation between MCD and the molecular profile of the primary tumor, but we noticed a strong correlation between intratumor MCD and lymph node metastases, regardless of the molecular type.

Corresponding author: Ramona Amina Popovici, Professor, MD, PhD; e-mail: ramona.popovici@umft.ro; Ioana Cristina Niculescu Talpos, MD, PhD; e-mail: ioana.talpos-niculescu@umft.ro

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14. Hormonal, apoptotic, proliferative and inflammatory markers expression in Desogestrel-treated women with ovarian endometriosis

Daniela-Roxana Matasariu, Ludmila Lozneanu, Irina Dumitrascu, Mihaela Grigore, Alexandra Elena Cristofor, Cristina Elena Mandici, Iuliana-Elena Bujor, Alexandra Ursache, Anca Daniela Braila, Alexandra Bausic, Romeo Micu

Endometriosis is a relatively frequent pathology in gynecological practice. We performed an analysis to demonstrate the molecular changes that occur in endometriosis synthetic progestin-treated patients, hoping to sketch a possible pathophysiological pathway that will help us to better understand and treat this debilitating disease. We conducted a prospective study that included a group of 40 women, evaluated in our hospital between 2020-2021. We evaluated immunohistochemical tissue expression of estrogen receptor (ER), progesterone receptor (PR), B-cell lymphoma 2 (Bcl-2) protein, Ki-67, and serum levels of osteopontin (OPN) and vascular endothelial growth factor (VEGF) in patients with ovarian endometrioma with and without progestin treatment. Our study revealed that Desogestrel treatment increases OPN serum levels, PR and Bcl-2 tissue expression and reduces VEGF serum levels and Ki-67 tissue expression. The results we have obtained are very interesting because the serum levels of OPN seem to be more influenced by progestin treatment, than by endometriosis itself. The study we have conducted gives a molecular complex view of what endometriosis represents and on how Desogestrel treatment works.

Corresponding author: Alexandra Ursache, Assistant Professor, MD, PhD; e-mail: carpalecsandra@yahoo.com; Anca Daniela Braila, Associate Professor, MD, PhD; e-mail: ancabraila@yahoo.com

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15. The role of cell adhesion molecules in the progression of bladder urothelial carcinomas

Andrei Stefan Sandulescu, Alex Emilian Stepan, Claudiu Margaritescu, Viorela Enachescu, George Mitroi, Cristiana Eugenia Simionescu

Alteration of the intercellular adhesion system plays an essential role in the initiation and progression of bladder carcinomas. We followed the immunoexpression of adhesion molecules, E-cadherin, beta-catenin and Claudin-1, in relation to the histopathological grade and the pT category in a number of 50 urothelial carcinomas of the bladder, based on a final staining score (FSS), calculated on the basis of reaction intensity and labeled cells number. E-cadherin immunoexpression was identified in the membrane of tumor cells, low FSS being associated with invasive high-grade carcinomas. beta-catenin reactions were membranous in the case of low-grade noninvasive carcinomas and predominantly cytoplasmic and nuclear in the case of high-grade invasive ones, for which high FSS were associated. Claudin-1 was identified at the membrane level, the high FSS values being more frequent in the case of high-grade invasive carcinomas, although there were no significant statistical associations. Loss of E-cadherin expression and the associated positive linear relation of beta-catenin and Claudin-1 indicate the usefulness of the analyzed markers in identifying the invasive aggressive phenotype of urothelial bladder carcinomas.

Corresponding author: Claudiu Margaritescu, Professor, MD, PhD; e-mail: c_margaritescu2000@yahoo.com; Alex Emilian Stepan, Professor, MD, PhD; e-mail: astepan76@yahoo.com

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16. Laryngeal malignancies - epidemiological data and particularities of the cases diagnosed in Western Romania (October 2016-July 2020)

Adrian Mihail Sitaru, Daniela Flondor, Stefania Dinu, Ioana Delia Horhat, Oana Andrada Iftode, Marioara Poenaru, Nicolae Constantin Balica, Flavia Baderca, Doina Georgescu, Doina Chioran, Cristian Andrei Sarau

In the last decade, the incidence and mortality associated with laryngeal malignancies has experienced an unfavorable evolution in Romania, in terms of this pathology the country that has become the leader, among the European Union (EU)-27 countries. The aim of the present retrospective study was to analyze the epidemiological data regarding laryngeal cancer and histopathological (HP) particularities in patients diagnosed in Western Romania. Within three years and 10 months (during October 2016-July 2020) in Ear, Nose and Throat (ENT) Clinic of Timisoara Municipal Emergency Clinical Hospital, 194 patients with laryngeal neoplasms (LN) were diagnosed. Most of the patients were male (93.8%), from Timis County, mainly and the neighboring Counties of Caras-Severin, Hunedoara, Mehedinti and Arad. Patient s average age (both sexes) was 62.6 years, with a range from 38 to 84 years and the highest percentages in the 60+ age group (48%). Regarding smoker status, the main cause of the development of the LN, 93.9% of patients were active ones. Regarding localization [International Classification of Diseases 11th Revision (ICD-11)], about 69% were malignant neoplasm of glottis (C32.0), followed by supraglottis (C32.1), larynx-unspecified (C32.9), and subglottis (C32.2). From the HP point of view, several types of tumors were identified, most of which were non-keratinized and keratinized squamous cell carcinomas (about 90%). In addition, there were identified types of verrucous carcinoma, acantholytic carcinoma, squamous papilloma, a possible pleomorphic sarcoma, and pyogenic granuloma. The data presented in this study highlight the growing incidence of LN, which mainly affect men, at an increasingly young age. It is imperative to involve specialists from nutrition, general medicine, ENT, dentistry to start awareness programs and to develop prevention protocols.

Corresponding author: Ioana Delia Horhat, Lecturer, MD, PhD; e-mail: deliahorhat@yahoo.com; Stefania Dinu, Lecturer, DMD, PhD; e-mail: dinu.stefania@umft.ro

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17. Morphometric study for the localization of the mental foramen in relation to the vertical reference plane

Victor Nimigean, Ovidiu Romulus Gherghita, Diana Loreta Paun, Elena Nicoleta Bordea, Angelo Pellegrini, Suzana Carmen Cismas, Vanda Roxana Nimigean, Natalia Motas

Background: The mental foramen (MnF) is the anatomic landmark where the mental neurovascular bundle exits the mandible. Precisely determining the position of the MnF is necessary before all dentoalveolar therapeutic procedures performed in the mandibular premolar area. Materials and Methods: For the study, we performed two ex vivo direct morphometric determinations on dry human dentate and edentate mandibles, and two in vivo imaging morphometric determinations through cone-beam computed tomography (CBCT) and orthopantomography (OPG) in dentate human patients. The following landmarks were used to locate the MnF: the distance between the MnF and the superior border of the mandible (MnF-SB), the distance between the MnF and the inferior border of the mandible (MnF-IB), and the position of the MnF in relation to the root apices of the posterior teeth. The results obtained from these data were processed statistically using the analysis of variance (ANOVA). Results: By direct morphometry on dentate mandibles, the MnF was situated closer to the IB and by direct morphometry on completely edentulous mandibles, the MnF was located closer to the SB. In both direct morphometry studies, the MnF transverse diameter was larger than the vertical one, with the MnF having an oval shape. ANOVA for both direct morphometry studies showed that the distances MnF-IB and MnF-SB significantly vary statistically with interactions and depending on age (p<0.00001). The vertical diameter of the MnF significantly varies statistically depending on age, interactions and between studies, and its transverse diameter varies statistically significantly with interactions and depending on age (p<0.00001). According to OPG and CBCT imaging studies, the MnF was located closer to the IB, and the transverse diameter of the MnF was larger than the vertical diameter; such results are similar to the direct morphometry study performed on dry dentate human mandibles. Regarding the position of the MnF in relation to the root apices, it was most frequently located inferior to the root apices in 79.45% of cases, in 19.23% of cases it was located at the root apices level and in 1.31% of cases it was located superior (coronal) to the root apices. ANOVA for both imaging morphometry studies showed that the MnF-IB distance varies statistically significantly with the interactions, the study, the sex of the patients and their age, the MnF-SB distance varies statistically significantly with the interactions, the study and the patients age (p<0.05), and the MnF diameters vary statistically significantly with interactions and patient age (p<0.05). Conclusions: The results of this study can help dental practitioners in improving dentoalveolar surgery procedures in the posterior mandible.

Corresponding author: Vanda Roxana Nimigean, Associate Professor, DMD, PhD; e-mail: vandanimigean@yahoo.com; Diana Loreta Paun, Associate Professor, DMD, PhD; e-mail: diana.paun@umfcd.ro

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18. Histological and immunohistochemical study of brain damage in traumatic brain injuries in children, depending on the survival period

Razvan Stefan Tolescu, Marian Valentin Zorila, Kamal Constantin Kamal, Marius Cristian Marinas, George Lucian Zorila, Camelia Oana Muresan, Roxana Eugenia Zavoi, Alexandru Constantin Oprica, Charoula Florou, Laurentiu Mogoanta, George Mitroi

Numerous studies showed that, at present, traumatic brain injury (TBI) is one of the main causes of death in young adults, but also a main cause of disabilities at all ages. For these reasons, TBI are continuously investigated. In our study, we evaluated the histopathological (HP) and immunohistochemical (IHC) changes that occurred in the brain in underage patients after a severe TBI depending on the survival period. We histopathologically and immunohistochemically analyzed a number of 22 cases of children, deceased in Dolj County, Romania, following some severe TBI, undergoing autopsy within the Institute of Forensic Medicine in Craiova between 2015-2020. Patients were divided into three groups depending on the survival period, namely: (i) patients who died during the first 24 hours of the accident; (ii) patients who died after seven days of survival; (iii) patients who died after 15 days of survival. Microscopic examinations of the brain fragments, collected during the necropsy examination, showed that the traumatic agent caused primary injuries in all brain structures (cerebral parenchyma, meninges, blood vessels). However, HP injuries ranged in size and intensity from one area to another of the brain. In patients with a longer survival period, there was observed the presence of smaller primary injuries and larger secondary injuries. There was also observed a growth in the number of meningo-cerebral microscopic injuries, depending on the increase of the survival period.

Corresponding author: Roxana Eugenia Zavoi, Professor, MD, PhD; e-mail: roxanazavoi@yahoo.com; George Lucian Zorila, University Assistant, MD, PhD; e-mail: zorilalucian@gmail.com

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19. Brachial and subclavian arteries aneurysms due to tuberous sclerosis complex mechanisms - case report and literature review

Dana Cristina Craiu, Alexandra Eugenia Bastian, Sabina Andrada Zurac, Sorin Liviu Baila, Marian Croitoru, Mihai Craiu, Radu Diaconu, Mihaela-Adela Vintan, Diana Gabriela Barca

Introduction: Tuberous sclerosis complex (TSC) is a rare autosomal dominant condition characterized by cutaneous, cerebral, and other multiorgan involvement. Aneurysms due to TSC pathogenic mechanism are rarely present, mainly aortic, renal, or intracranial and very few associated with peripheral circulation. A TSC patient, aged 31 years, who developed brachial and subclavian arteries aneurysms is presented. The question of a random association of the aneurysms with TSC versus aneurysms within pathogenic released mammalian target of rapamycin (mTOR) pathway effect was raised. Case presentation: Patient s file, available from the age of six months, was analyzed for demonstration of the TSC diagnosis. Patient was examined, and cerebral magnetic resonance imaging (MRI) was repeated. Surgery and angiographic reports and images were reviewed. Pathology of the aneurysmal wall available from surgery was reexamined and special stainings and immunohistochemistry markers were applied. Genetic characterization of the patient was performed. Definite TSC was diagnosed based on major criteria [ungual fibromas, shagreen patch, cortical tubers, subependymal nodules (SENs), subependymal giant cell astrocytoma (SEGA)], minor criteria (confetti skin lesions, dental enamel pits, gingival fibromas), genetic result showing heterozygous variant in exon 8 of TSC1 gene (c.733C>T-p.Arg245*). Pathology analysis revealed markedly thickened aneurysmal wall due to smooth muscle cells (SMCs) proliferation in media and neoformation vessels with similar characteristics in the aneurysmal wall. Discussions and Conclusions: This is a rare case with aneurysms related to TSC, with an exceptional peripheral localization. Pathology exam is the key investigation in demonstrating the TSC-related pathogenic mechanism. A literature review showed 73 TSC cases presenting aneurysms published until now.

Corresponding author: Mihai Craiu, Associate Professor, MD, PhD; e-mail: mcraiu@yahoo.com; Radu Diaconu, Lecturer, MD, PhD; e-mail: raduteodiaconu@yahoo.com

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20. A 64-year-old woman with primary synovial sarcoma of the abdominal wall

Matheus Dantas Gomes Goncalves, Lister Arruda Modesto dos Santos, Vitorino Modesto dos Santos, Isabel Butter Amim, Francisco Pimenta Marques, Eduardo Diogenes Fonseca

Synovial sarcoma (SS) usually affects joints, bursae, and tendons of extremities and is very infrequent in the head and neck, abdomen, thorax, prostate and kidney, skin, blood vessels, and nerves. Primary intra-abdominal SS is exceeding uncommon and has non-specific symptoms or compress surrounding structures. The diagnosis is a challenge, and histopathological and immunohistochemical studies must confirm the hypothesis. We report the case of SS that has origin in peritoneal structures and a longstanding unsuspected course. The patient was a 64-year-old woman who claimed chronic pain in the left iliac fossa, without additional symptoms. She related laparoscopic oophorectomy, cholecystectomy, and abdominal hysterectomy in the previous three decades. There was neither local invasion nor lymph nodal, vascular or neural invasion, and her surgical treatment by open abdominal procedure was uneventful. The herein reported case aims to enhance the index of suspicion.

Corresponding author: Vitorino Modesto dos Santos, Professor, MD, PhD; e-mail: vitorinomodesto@gmail.com

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21. Epithelioid hemangioendothelioma - an unexpected diagnosis of a mediastinal tumor with extensive local thrombosis

Mircea Litescu, Tamer Abduraim, Laura Paverman, Camelia Doina Vrabie, Ion Dina, Iancu Emil Plesea, Valentin Titus Grigorean

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor and the mediastinal localization is amongst the most infrequent. We present the case of a 37-year-old woman with a history of resected left thyroid tumor that presented to our department for evaluation of a left supraclavicular palpable mass in close contact with local vascular structures, and with heterogeneous contrast enhancement as described by computed tomography (CT) and magnetic resonance imaging (MRI). Considering the history of the patient, the presumptive diagnosis of thyroid tumor recurrence was established, and the patient was referred to surgical department. During procedure, we encountered important bleeding from a ruptured jugular vein branch, which we assumed to be a newly formed tumor blood vessel. After surgery (48 hours postoperatively), the patient developed important local thrombosis that encompassed the left internal jugular vein, left subclavian vein and the left brachiocephalic trunk that partially subsided after anticoagulant therapy. The histological examination revealed the presence of a vascular tumor proliferation of epithelioid endothelial cells that was characteristic of an EHE confirmed later on the immunohistochemical studies as Yes-associated protein 1-transcription factor E3 (YAP1-TFE3) subtype. In addition to the case report, some relevant information from the scarce literature data about mediastinal EHE were reviewed here.

Corresponding author: Iancu Emil Plesea, Professor, MD, PhD; e-mail: emil.plesea@umfcd.ro

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22. Fetal sacrococcygeal immature teratoma - report of two cases and review of the literature

Madalina Lucia Marcu, Nicolae Bacalbasa, Elisabeta Candrea, Catalina Diana Stanica, Tarig Massawi, Andreea Chirilov, Adrian Neacsu, Irina Pacu

Sacrococcygeal teratomas (SCTs) are rare congenital tumors. With the improvement of diagnostic imaging methods and follow-up protocols in pregnancies, in utero detection of these tumors has increased. Despite these progresses, SCTs may present difficulties in establishing in utero diagnosis and subsequent management. We present two cases of SCT in 18 weeks, respectively 22 weeks pregnancy, diagnosed using ultrasound imaging and pathologically confirmed. Also, the article aims to recapitulate clinicopathological aspects and prognosis of these lesions, following the review of the literature.

Corresponding author: Catalina Diana Stanica, Assistant, MD, PhD; e-mail: catalina.stanica@umfcd.ro

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23. Cervical intranodal schwannoma - a rare diagnosis

Daniel Mirea, Marius Claudiu Manea, Nona Ionela Bejinariu, Bogdan Mocanu, Alina Mihaela Ciocalteu, Mirela Tiglis, Ileana Peride, Tiberiu Paul Neagu, Liliana Elena Mirea, Ioan Lascar

Intranodal schwannoma is a rare benign tumor, which originates from the peripheral nerve sheath (Schwann cells), fewer cases being reported with lymphatic involvement. We present the case of a middle-aged female patient, with one-year growing mass in the lateral-cervical area, in intimate relation with the vascular package of the neck. Preoperative cervical computed tomography examination showed the tumor features. There was no intraoperative complication, with the piece being completely removed. The morphological examination revealed the structure of a lymph node, and after Hematoxylin-Eosin staining, there were eosinophilic cytoplasm, euchromatic nuclei, with round, elongated or slightly wavy form and reduced pleomorphism, rare degenerative nuclear atypia, and no mitotic activity nor necrosis. The expression of S100 protein on immunohistochemistry, along with negative results for smooth muscle actin and desmin sustained the diagnosis of intranodal schwannoma of the neck. With a low index of cellular proliferation (Ki67), this case is in line with the reported features of schwannoma having extremely rare malignant transformation.

Corresponding author: Tiberiu Paul Neagu, Assistant Professor, MD, PhD; e-mail: dr.neagupaul@gmail.com; Liliana Elena Mirea, Associate Professor, MD, PhD; e-mail: llmirea@yahoo.com

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24. Retinal morphological and functional response to Idebenone therapy in Leber hereditary optic neuropathy

Maria Filofteia Mercut, Cornelia Andreea Tanasie, Alexandra Oltea Dan, Andreea Mihaela Nicolcescu, Oana Maria Ica, Carmen Luminita Mocanu, Alin Stefan Stefanescu-Dima

Leber hereditary optic neuropathy (LHON) is a mitochondrial disease leading to optic atrophy due to degeneration of the retinal ganglion cell. A curative treatment is not available at the moment, but a new antioxidant drug, Idebenone, is expected to reduce the progression of the disorder. Two male patients, genetically confirmed with LHON, were clinically, morphologically, and electrophysiologically evaluated, before and three, six, nine and 12 months after starting the treatment. The patient with 3460G>A mutation in mitochondrially-encoded nicotinamide adenine dinucleotide, reduced form (NADH):ubiquinone oxidoreductase core subunit (mtND)1 gene showed an improvement in visual acuity, visual field, and visual evoked potentials with no effect on morphological examinations, while the patient with 11778G>A mutation in mtND4 gene showed no functional, nor morphological recovery after one year of treatment. This study demonstrates that Idebenone, depending on the genetic profile of the disease, may be effective in functional improvement in patients with LHON.

Corresponding author: Cornelia Andreea Tanasie, Teaching Assistant, MD, PhD; e-mail: corici.andreea@gmail.com

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25. Basaloid squamous cell carcinoma with prominent shadow (ghost) cell differentiation. An unreported neoplasm of the parotid gland

Jose-Fernando Val-Bernal, Gonzalo Herrera, Alejandro Fernandez-Florez, María Martino

Basaloid squamous cell carcinoma (BSCC) is an aggressive type of squamous cell carcinoma (SCC) predominant in the upper aerodigestive tract. To our knowledge, only one case of that tumor has been previously described in the parotid gland. Shadow (ghost) cell differentiation (SCD) is a specialized form of keratinization characteristic of pilomatricoma, and other skin tumors with follicular differentiation. SCD has also been described infrequently in some visceral carcinomas and rarely in the minor salivary glands. Recently, an SCC with prominent SCD has been reported in the parotid. We report for the first time the case of parotid BSCC with prominent SCD in an 87-year-old man. He was admitted due to the appearance in the last few months of a mass, painful on palpation, in the left parotid region. Imaging studies and tru-cut biopsies indicated the need for surgical removal. A left superficial parotidectomy, including the branch of the cervicofacial nerve, was performed. The BSCC showed predominance (62%) of SCD. Immunohistochemically, the basaloid cells were positive for beta-catenin, pan-cytokeratin (pan-CK) AE1/AE3, CK19, high-molecular-weight CK (HMWCK), p63, p40, and cluster of differentiation 10 (CD10) in a diffuse pattern. No signs of recurrence or metastasis were observed four months after surgery. The main differential diagnoses include nuclear protein in testis (NUT) carcinoma, adamantinoma-like Ewing sarcoma, embryonal carcinoma, and basal cell adenocarcinoma of the solid type. SCD in BSCC of the parotid should be recognized to avoid misdiagnosis, especially in small samples. Although rare, BSCC with SCD should be added to the list of tumors that may originate in the parotid gland.

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

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26. Fetal-maternal incompatibility in the Rh system. Rh isoimmunization associated with hereditary spherocytosis: case presentation and review of the literature

Simona-Daniela Neamtu, Marius Bogdan Novac, Adela-Valeria Neamtu, Iulia Diana Stanca, Mihail Virgil Boldeanu, Adrian Gluhovschi, Liliana Stanca, Anda Lorena Dijmarescu, Maria Magdalena Manolea, Magdalena Rodica Traistaru, Garofita-Olivia Mateescu, Mirela Anisoara Siminel

Next to A and B antigens, agglutinogen D exhibits the highest immunogenicity. Following the transfusion of D-positive red blood cells (RBCs), almost 80% of D-negative recipients develop anti-D antibodies (Abs). Subsequently, anti-D immunization further promotes the synthesis of Abs towards other blood group antigens in or outside the Rh system. The D antigen is also involved in 95% of cases of hemolytic disease of the newborn. Transfusions, hemotherapy, grafts, and obstetric history (abortions, ectopic pregnancy, births) are all risk factors for Rh isoimmunization. In the case of ABO compatibility between mother and fetus, Rh-positive fetal RBCs that have reached the maternal bloodstream are not destroyed by group agglutinins, and Rh antigenic sites are not hidden by the maternal immune system. But a Rh-negative mother with a homozygous Rh-positive husband will certainly have a Rh-positive fetus. As it has an irreversible evolution, the Rh isoimmunization once installed cannot be influenced in the sense of decreasing the Ab titer, therefore, injectable globulin has no effect. A particular case was that of a newborn with Rh system incompatibility associated with hereditary spherocytosis The clinical balance at birth reflects the severe jaundice of the female newborn of 3140 g, gestational age 38/39 weeks, extracted by lower-segment transverse Caesarean section, with a double loop nuchal cord, Apgar score 8. Because the jaundice was severe and atypical (face and upper chest), we considered the possibility of coexistence of hemolytic disease of the newborn by Rh blood group incompatibility associated with hereditary spherocytosis, as it turned out to be true and mentioned. Changes in genes encoding proteins in the structure of the RBC membrane have amplified hemolysis induced by maternal-fetal isoimmunization in the Rh system. Massive hemolysis accentuated by congenital spherocytosis, confirmed later, imposed blood transfusion and dynamic monitoring.

Corresponding author: Adela-Valeria Neamtu, MD, Resident Physician; e-mail: nav29.adela@yahoo.com; Liliana Stanca, Lecturer, MD, PhD; e-mail: lillystanca@yahoo.com

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27. Half abdomen tumor - giant retroperitoneal lipoma: a case report and review of the literature

Razvan-Cosmin Petca, Valentin Ambert, Razvan-Ionut Popescu, Cristian Mares, Aida Tincuta Petca, Costin Berceanu, Viorel Jinga

The pure retroperitoneal lipoma is a sporadic benign tumor originating from the mesenchymal tissue. There are only a few data in the literature. The technique available at this moment cannot establish a clear distinction between a benign adipose mass and a low-grade liposarcoma. This study presents the case of a 53-year-old man presenting computed tomography (CT) and magnetic resonance imaging (MRI) findings that revealed a giant retroperitoneal fatty tumor of 365/210/165 mm dimensions, suspected of malignancy. The patient s medical history, clinical data, and blood tests are more likely inclined to a benign condition. Liposarcoma couldn t be excluded preoperatively. The patient underwent an open surgical procedure respecting the oncological principles, with complete resection of 6400 g of retroperitoneal adipose tumor that also affected the surrounding organs normal abdominal anatomy. The tumor was relatively well delimited without any signs of local invasion or infiltration. Three solid masses described on the MRI were identified upon dissection and sent separately for histological examination. The result indicated a giant retroperitoneal lipoma with benign characteristics. Facing imagistic difficulties to distinguish lipoma from liposarcoma clearly, and the inconclusiveness of fine-needle biopsies, oncological resection remains the only option as a diagnostic method and curative treatment.

Corresponding author: Razvan-Ionut Popescu, Assistant Professor, MD, PhD Student; e-mail: razvan-ionut.popescu@drd.umfcd.ro; Costin Berceanu, Associate Professor, MD, PhD; e-mail: dr_berceanu@yahoo.com

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28. Complete morphofunctional oral rehabilitation by physiological increase of occlusal vertical dimension according to computerized mandibular scanner

Florin-Eugen Constantinescu, Fabio Savastano, Paula Perlea, Marian-Vladimir Constantinescu

Increasing the occlusal vertical dimension (OVD) is often indicated in complex oral rehabilitation to gain restorative space and improve the occlusal relationship and aesthetics. The effect of increasing the OVD on lower facial height and facial aesthetics is not well understood and evaluated. The authors present the philosophy of the neuromuscular concept and illustrate it through a case report of a 58-year-old female patient who presented severe deep bite, bruxism, and temporomandibular disorders (TMDs). After clinical evaluation, the extraoral examination showed a reduction of the lower facial height, protuberant lips, wrinkles, and over-closed commissures. In addition, intraoral examination showed a severe anterior deep bite articulation, and the upper incisors completely covering the lower incisors labial surfaces. Through the philosophy of the neuromuscular concept the diagnostic ability, the quality and stability of the treatment increases. A temporary long-term fixed prosthesis was made at the enlarged OVD to be used in the first stage of the rehabilitation. Compared to the initial situation, the new prosthesis was delivered at a vertical dimension (VD) higher with 7 mm. The purpose of the neuromuscular philosophy and methodology is to harmonize the facial profile, functional occlusion, the joint function, and neuromuscular control. Through the neuromuscular methodology, we can assess the patient s ability to manage a significant increase in VD and to restore a functional OVD by physiological measurements.

Corresponding author: Florin-Eugen Constantinescu, DDS, MSc, PhD Student; e-mail: AL399897@uji.es, florin-eugen.constantinescu@drd.umfcd.ro, Dr.florin.constantinescu@gmail.com; Paula Perlea, Professor, DDS, PhD; e-mail: paula.perlea@gmail.com

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29. Role of histopathology in the management of the gingival enlargement in a patient on antihypertensive therapy based on calcium channel blockers: a case report

Stana Paunica, Sabina Andrada Zurac, Anca Silvia Dumitriu, Stefana Popa, Claudiu Gabriel Socoliuc, Marina Cristina Giurgiu

Periodontal pathology is often represented by increases in gingival volume, with pronounced inflammatory phenomena. These manifestations require a more accurate diagnosis and knowledge of the etiopathogenic factors involved. The periodontal treatment applied must be related with the etiopathogenic circumstances. Periodontal disease sometimes has a complex appearance, with intertwined local and systemic favorable factors that make it difficult to include it in a certain taxonomic form. Also, in general, the adult patients have associated chronic diseases that involve the administration of several drugs, which induce on long-term both therapeutic and side effects. Furthermore, diseases in the oral cavity may occur frequently, which require complex and associated dental and periodontal treatment, also occlusal rebalancing, which is a real interdisciplinary challenge. In this case report, periodontal status is determined by a combination of local and systemic favorable factors. However, the histopathological analysis of the gingival samples revealed inflammation without characteristic fibrous hyperplasia changes of the Amlodipine calcium channel blocker (CCB) administration, the antihypertensive medication of the patient. Thus, Amlodipine does not have a hyperplasic effect on gingival mucosa in all cases. Therefore, even if they are more expensive, investigations must be complex, if necessary, in establishing the involvement of the side effect of the systemic medication in periodontal pathological changes. CCB systemic medication is essential, even vital, for maintain the arterial pressure at normal values, should not be altered without the real indication and to the recommendation from a specialist doctor, and the periodontal treatment must be focused to eliminate the local factors.

Corresponding author: Anca Silvia Dumitriu, Professor, DMD, PhD; e-mail: anca.dumitriu@umfcd.ro; Stefana Popa, DMD, PhD Student; e-mail: stefana.popa@drd.umfcd.ro

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30. Conference Announcement: The XVIIIth National Symposium, with international participation, on Microscopic Morphology, Craiova, Romania, October 12-15, 2022

Laurentiu Mogoanta

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