ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 65 No. 3, July-September 2024

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

Rada Teodora Sufletel, Carmen Mihaela Mihu, Adina Bianca Bosca, Carmen Stanca Melincovici, Mariana Viorica Marginean, Elena Mihaela Jianu, Madalin Mihai Onofrei, Anne-Marie Constantin, Ioana Maria Moldovan, Andrei Coneac, Andreea Crintea, Roxana Adelina Stefan, Paul-Andrei Stefan, Bogdan Alexandru Gheban, Lavinia Patricia Mocan, Alina Simona Sovrea

The paper provides an overview of the current understanding of different cells and structures biology [e.g., blood-retinal barrier, Bruch membrane, Clara (club) cells, brush cells and tuft cells, Merkel cells, Hofbauer cells, cytokeratins], including their origin, structure, function, and role in disease pathogenesis, and of the latest findings in the medical literature concerning the paracortex of the lymph nodes.

Corresponding author: Anne-Marie Constantin, Lecturer, MD, PhD; e-mail: annemarie_chindris@yahoo.com

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2. Are HPV oncogenic viruses involved in salivary glands tumorigenesis?

Constantin Aleodor Costin, Mariana Bianca Chifu, Diana Lavinia Pricope, Adriana Grigoras, Raluca Anca Balan, Cornelia Amalinei

The association between different viruses and cancer is well acknowledged in human pathology. However, the precise understanding of how oncogenic viruses intervene in the development of cancer of salivary glands (SGs) remains incomplete. Our review aimed to explore the current literature regarding SGs cancer to evaluate the potential involvement of human papillomaviruses (HPVs) in their development. Our work hypothesis suggests that viruses may be involved in these tumors immunogenicity. The literature analysis showed HPV-positive detection in different head and neck malignancies, added to variable risk factors and a constant increasing incidence rate. HPV tumorigenesis mechanism is complex, involving E6 and E7 HPV oncoproteins. Additionally, the reported findings generally support the relationship between SGs cancer and high oncogenic subtypes 16 and 18. However, the pathogenic contribution of HPV subtypes 11, 33, 45, 52, 56, and 59 is controversial and further research may clarify their potential involvement in the SG tumor s development. This literature review may enhance the understanding of the role of viral contribution as an etiopathogenic co-factor in SG carcinogenesis. Thus, these data may add value to innovative concepts and treatment strategies development, given that virus-induced tumors can be prevented by targeted immunization, added to oncolytic or viral therapy.

Corresponding author: Raluca Anca Balan, Professor, MD, PhD; e-mail: raluca.balan@umfiasi.ro

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3. Synthesis and characterization of hydroxyapatite-zinc oxide nanocomposites incorporating rosemary and thyme essential oils for enhanced bone regeneration and antimicrobial activity

Alexandra-Cristina Burdusel, Delia Sarchizian, Adelina-Gabriela Niculescu, Alina Maria Holban, Roxana-Cristina Popescu, Roxana Trusca, Ecaterina Andronescu

The study presents a novel approach to bone regeneration using bioactive nanocomposites. The research focuses on creating hydroxyapatite (HAp) and zinc oxide (ZnO) nanocomposites functionalized with rosemary and thyme essential oils (EOs) to enhance osteogenic and antimicrobial properties. The findings reveal that the incorporation of EOs not only improves biocompatibility by reducing Zn-induced cytotoxicity but also enhances antimicrobial activity, particularly against Gram-negative and Gram-positive bacteria. Additionally, thyme EO exhibits a more potent effect in enhancing cell viability and antibacterial efficacy compared to rosemary EO. Structural analyses through X-ray diffraction (XRD), scanning electron microscopy (SEM), and Fourier-transform infrared (FT-IR) spectroscopy confirm the successful synthesis of well-integrated HAp-ZnO structures with the EOs. This study offers promising insights into the potential of functionalized nanocomposites for biomedical applications, especially in bone regeneration and infection prevention.

Corresponding author: Ecaterina Andronescu, Professor, PhD; e-mail: ecaterina.andronescu@upb.ro

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4. Nuclear morphology explained through digital morphometry: differentiating nuclear features across the three histological grades in cutaneous squamous cell carcinoma

Alexandra Buruiana, Mircea-Sebastian Serbanescu, Bogdan Pop, Bogdan-Alexandru Gheban, Ioana-Andreea Gheban-Rosca, Carmen Georgiu, Doinita Crisan, Maria Crisan

Introduction: The accurate grading of cutaneous squamous cell carcinoma (cSCC) is crucial for effective treatment and patient care, but the current method, relying on pathologist visual assessment, can be subjective. Aim: This study aimed to quantitatively investigate nuclear morphometrics in cSCC tumor cells, specifically examining potential differences between established histological grades and exploring the utility of digital morphometrics in characterizing nuclear morphology. Materials and Methods: We analyzed 47 cSCC cases, utilizing whole slide images and CellProfiler software to extract nuclear morphometric features from a total of 519 828 nuclei. Results: The results showed significant differences in nuclear size, shape, and spatial arrangement between different tumor grades. Notably, grade 3 tumors exhibited distinct characteristics compared to grades 1 and 2, suggesting a potential shift towards a simplified, 2-tier grading system. Conclusions: The study highlights the potential of digital morphometrics as a valuable tool for enhancing the accuracy and objectivity of cSCC grading, ultimately improving patient care.

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

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5. MAPLE-prepared graphene oxide-based coatings for improved orthopedic screws used in knee interventions

Sorin Constantinescu, Oana Gherasim, Gabriela Dorcioman, Valentina Grumezescu, Gheorghe Iosub, Adelina-Gabriela Niculescu, Elena-Theodora Moldoveanu, Dragos Mihai Radulescu, Alexandru Mihai Grumezescu, Miruna Silvia Stan, Alina Maria Holban, Adrian-Radu Radulescu

Orthopedic screws are subjected to high mechanical stress, corrosive environment, and microbial colonization, which may cumulatively lead to implant failure and periprosthetic joint infections. To overcome these issues, this study has focused on modifying the surface chemistry and topography of screws utilized in knee intervention toward enhancing their mechanical and biological behaviors. Specifically, this study has explored the optimization of composite coatings made of polycaprolactone (PCL), graphene oxide (GO), and Meropenem (MRP) via the matrix-assisted pulsed laser evaporation (MAPLE) technique. The PCL/GO/MRP coatings aimed to upgrade the surfaces of the implantable fixation devices, offering superior antimicrobial properties, reduced biofilm formation, and better mechanical characteristics. Comprehensive physicochemical analyses, including Fourier-transform infrared spectroscopy (FTIR), scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDS), and Raman microscopy, confirmed uniform deposition, efficient material transfer, and preservation of functional groups. The developed coatings displayed significant antibacterial activity against Staphylococcus aureus and Escherichia coli, with a marked reduction in biofilm formation compared to uncoated surfaces. Thus, this work highlights the potential of the designed PCL/GO/MRP coatings as a strategy to enhance the biocompatibility and longevity of orthopedic screws, minimize complications related to implant-associated infections in knee surgeries, and ultimately improve post-surgical outcomes to increase patients quality of life.

Corresponding author: Adelina-Gabriela Niculescu, Chem Eng, PhD Student; e-mail: adelina.niculescu@upb.ro; Dragos Mihai Radulescu, Assistant, MD, PhD; e-mail: dragos.radulescu@umfcd.ro

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6. Conservative management of cervical intraepithelial neoplasia 2 and prediction of its progression - a retrospective study

Alexandru Carauleanu, Raluca Anamaria Mogos, Iustina Petra Solomon-Condriuc, Claudia Florida Costea, Andrei Ionut Cucu, Stefana Raluca Bran, Adina Elena Tanase, Gabriel Valentin Tanase, Elena Andreea Pruteanu, Demetra Gabriela Socolov, Florin Dumitru Petrariu, Catalin Mihai Buzduga

Aim: Cervical intraepithelial neoplasia 2 (CIN2) evolution is controversial, and some of them regress spontaneously in a two-year follow-up. The purpose of this work was to evaluate the percentage of CIN2 progression or persistence during a 24-month follow-up, using clinical predictors such as human papillomavirus (HPV) genotype and cytology results. Patients, Materials and Methods: This is a retrospective case-control study and included patients of reproductive age who had a new diagnosis of CIN2 who were monitored for lesion regression (Group 1, n=72 patients), and progression or persistence (Group 2, n=36 patients). A multinominal logistic regression was preferred to evaluate the impact that various categorical risk elements can lead to outcomes of persistence or progression of CIN2. We also performed a linear regression to assess the risk of CIN2 progression or persistence using the interaction between clinical predictors. Results: A previous cervical cytology indicative of high-grade squamous intraepithelial lesion (HSIL) [relative risk ratio (RRR): 3.85, 95% confidence interval (CI): 1.66-8.90] or atypical squamous cells, cannot exclude HSIL (ASC-H) can highly raise the probability of a CIN2 progression or persistence. The presence of HPV16 increased the risk of CIN2+ with 3.77 (95% CI: 0.78-5.00), the presence of HPV18 increased the probability of CIN2+ with 4.39 (95% CI: 1.35-14.33), and other high-risk HPV (HR-HPV) strains increased the probability of CIN2+ with 3.62. The highest risk issue was produced by the interaction between HSIL* HPV16, ASC-H* HPV16, and ASC-H* HPV18. Conclusions: When discussing follow-up for CIN2 lesions, it is important to offer careful consideration and monitoring of patients with a previous HSIL or ASC-H cytology, with or without HPV 16, 18 or other HR-HPV strains, as their presence significantly increased the risk of CIN2 progression and persistence.

Corresponding author: Claudia Florida Costea, Professor, MD, PhD; e-mail: costea10@yahoo.com; Iustina Petra Solomon-Condriuc, MD, PhD; e-mail: iustina_condriuc@yahoo.com

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7. Outcome in acute ischemic stroke patients treated with intravenous thrombolysis - a retrospective and statistical analysis of five years experience

Mihai-Marius Botezat, Adriana-Gabriela Caragea, George Popescu, Gabriela Camelia Rosu, Marian Valentin Zorila, Tiberiu Stefanita Tenea-Cojan

This paper represents a retrospective study on 252 patients with acute ischemic stroke (AIS), who received thrombolytic therapy between 2019-2023, in the Department of Neurology at the Emergency County Hospital in Craiova, Romania. We aimed to evaluate treatment complications and short-term outcomes of patients with AIS, treated with intravenous (i.v.) recombinant tissue plasminogen activator (rtPA; Alteplase), within 4.5 hours from onset. We also tried to assess the correlations between classical risk factors, such as diabetes, hypertension, atrial fibrillation, smoking and the outcome of these patients. Two hundred and fifty-two patients were treated with i.v. thrombolysis in our Department between October 2019 and December 2023. Out of the total thrombolysed patients, 146 were men and 106 were women. Our focus was on the clinical evolution of our patients and on the complications, especially on hemorrhagic transformation and death, and we tried to see if there were any correlations between gender, age, vascular risk factors such as diabetes, smoke, obesity, hypertension, atrial fibrillation and the outcome of our thrombolysed patients. Out of the total of 252 thrombolysed patients, only 55 (21.83%) had hemorrhagic transformation. Analyzing the differences between the occurrence of hemorrhagic transformation, respectively death, depending on the location and type of stroke, we did not identify statistically significant differences. The only comparison where a difference close to the significance limit is observed is that related to the frequency of deaths depending on the type of stroke - patients with cardioembolic stroke had a higher death rate.

Corresponding author: Gabriela Camelia Rosu, Teaching Assistant, MD, PhD; e-mail: nicola_camelia92@yahoo.com

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8. Histopathological and immunohistochemical characteristics of adult renal tumors: a five-year retrospective study in Mures County, Romania

Andrada Loghin, Andrada Raicea, Maria Catalina Popelea, Ciprian Doru Todea-Moga, Oliver Arpad Vida, Angela Borda

Introduction: The incidence of renal tumors increased substantially in the past decades, being responsible for 3% of deaths caused by cancer globally. They constitute a diverse group with varying morphological, immunohistochemical, and molecular characteristics. The severity and prognosis are directly correlated with tumor stage, histopathological aspect, sarcomatoid/rhabdoid features, fat or vascular invasion. Aim: The aim of the study was to assess the prevalence trend, as well as demographic and pathological characteristics of renal tumors in Mures County Clinical Hospital, Romania, and border areas. Patients, Materials and Methods: In this retrospective study, all patients who underwent a total or partial nephrectomy for renal tumors were analyzed over a five-year period. The data was collected from the Pathology Department of Mures County Clinical Hospital. Results: Among 220 patients, 138 (62.72%) were males and 82 (37.27%) females. The mean age was 62.63 years (range: 33-84 years). The majority of the tumors found were malignant: 204 (92.72%) vs 16 (7.27%) benign. The most common subtype within malignant tumors was clear cell renal cell carcinoma (CCRCC) (n=181), 13.25% cases with sarcomatoid/rhabdoid features. pT3a stage was frequently identified. Vascular invasion and necrosis were observed in a large number of cases, especially for CCRCC with sarcomatoid/rhabdoid features. Conclusions: The spectrum of adult renal tumors in our region aligns with the data reported in the literature. CCRCC was the most frequent histological subtype and pT3a the most common stage identified. Our study contributes to the understanding of renal tumors characteristics, identifying potential factors with impact in the progression and prognosis of the disease.

Corresponding author: Andrada Raicea, MD, PhD Student; e-mail: andrada.raicea@umfst.ro

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9. Influence of maternal rats hypothyroidism on morpho-functional peculiarities and glycome of progeny skin

Khrystyna Strus, Ilona Chelpanova, Roman Onysko, Iryna Dasyuk, Arthur Poliiants, Antonina Yashchenko, Taras Dasyuk, Alexander Lutsyk

We studied the influence of maternal hypothyroidism on progeny skin morphogenesis by means of histological, histochemical and lectin-histochemical methods. Hypothyroid conditions in rats were achieved by daily food supplementation with antithyroid drug Mercazolil. The experiment was conducted on 10 control and 10 hypothyroid rats, which delivered 70 and 46 offsprings, respectively. We discovered that maternal hypothyroidism induces the accumulation of mast cells (MCs) in the skin of progeny on the 1st, 10th and 20th postnatal days, with decrease of these cell s count returning to control level on 40th postnatal day. These results indicate that offsprings developing under conditions of maternal hypothyroidism are a risk group for changes in immune status and the occurrence of allergic reactions. The stratum corneum of epidermis, its lipid barrier as well as pilosebaceous units, in both control and experimental group animals, at the early stages of postnatal ontogenesis are enriched with carbohydrate determinants of alphaDMan, betaDGal, betaDGal(1-3)DGalNAc, alphaLFuc, alphaDGalNAc, alphaDGlcNAc, Neu5Ac. Galanthus nivalis agglutinin (GNA) is a selective histochemical marker of MCs, while Lactarius torminosus fungus agglutinin (LTFA) is a selective label of Langerhans cells. Maternal hypothyroidism resulted in reduction of lectin binding with the structural components of progeny skin and its derivatives. We speculate that alterations in glycoconjugate processing and degradation sequences have an impact on the cell signaling, formation of adhesive contacts, cellular proliferation and differentiation. The lectin set we used clearly demonstrated specific labeling of cellular subpopulations, monitoring glycoconjugates processing and degradation under physiological and pathological conditions in all skin components.

Corresponding author: Alexander Lutsyk, Professor, MD, PhD; e-mail: lutsykalexander@gmail.com

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10. Evaluation of epidemiological and pathological features of symptomatic spinal metastases in Romania - what could we learn from a retrospective study?

Stefan Selaru, Lucian Eva, Anca Sava, Gabriela Florenta Dumitrescu, Marius Gabriel Dabija, Vladimir Poroch, Anton Knieling, Cristinel Ionel Stan, Lucia Corina Dima-Cozma, Mihaela Tomaziu-Todosia, Ana Maria Dumitrescu, Viorel Scripcariu

Metastases are the most common tumors of the spine. As an important increase in the annual incidence of spinal metastases (SMs) has been observed in the last decade, the aim of this study was to describe the epidemiology and histopathological types of SMs surgically treated in the Neurosurgery Clinics of a Regional Hospital in North-Eastern Romania over a period of five years, in order to define a certain tumor profile that would benefit from an early screening. We retrospectively evaluated 115 adult patients, searching for demographic data (gender and age of the patients), primary tumor characteristics (location and histological type), topography of the SMs, and the time interval between the diagnosis of the primary tumor and the surgery for the SMs. The patients were elderly (average age: 58.96 years), with a male predominance (67.82%). Main location of SMs was in thoracic region (44.34%), with multiple vertebral metastases in 30.43% of patients. Only 33.04% of the patients had a known cancer at the time of admission. Primary tumor was located mainly in lung (47.82%), gastrointestinal tract (15.65%), breast (11.30%), prostate (10.43%) and kidney (9.56%). SMs from lung cancer (LC) mostly expressed squamous cell carcinoma (19.13%), probably due to patients smoking habits, and those from the digestive system mostly exhibited a moderately/poor colorectal adenocarcinoma (8.69%). Our data suggest the need for close surveillance of patients diagnosed with LC and colorectal cancer because these malignancies most frequently develop SMs. Smoking prevention actions and screening programs for the detection and removal of precancerous colorectal lesions must be developed and expanded.

Corresponding author: Anca Sava, Professor, MD, PhD; e-mail: dr.anca.sava.68@gmail.com; Cristinel Ionel Stan, Professor, MD, PhD; e-mail: cristi_stan00@yahoo.com

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11. Evaluation of the lymphocyte population and placental inflammation in pregnant patients with moderate or severe COVID-19 forms - a secondary analysis

Adina Elena Tanase, Raluca Anamaria Mogos, Simona Juliette Mogos, Stefana Raluca Bran, Tudor Catalin Gisca, Iustina Petra Solomon-Condriuc, Claudia Florida Costea, Gabriel Valentin Tanase, Andrei Ionut Cucu, Demetra Gabriela Socolov, Florin Dumitru Petrariu, Elena Andreea Pruteanu, Razvan Vladimir Socolov, Catalin Mihai Buzduga, Alexandru Carauleanu

Aim: In this secondary analysis, we aimed to characterize the lymphocytes population and placental inflammation in pregnant women with moderate and severe coronavirus disease 2019 (COVID-19) forms. Patients, Materials and Methods: In the analysis of this prospective evaluation, we included 26 pregnant women at term with moderate and severe COVID-19 forms that were evaluated in a tertiary maternity center in a one-year timeframe. Clinical data, along with blood immunophenotyping results and placental histopathological examinations were comparatively evaluated between two study groups depending on the COVID-19 severity: Group 1 (moderate COVID-19, n=14 patients) and Group 2 (severe COVID-19, n=12 patients). Results: Pregnant patients with severe COVID-19 presented significantly lower total amount of lymphocytes (p<0.001), T-lymphocytes (p=0.009), cluster of differentiation (CD)4+ T-cells (p=0.002), B-lymphocytes (p=0.001). Also, the number of CD4+ T-cells (p=0.01), CD8+ T-cells (p=0.02) and B-lymphocytes (p=0.002) was lower enough for cases with severe COVID-19. Conclusions: Lymphocytopenia could be a useful hematological marker for risk stratification of COVID-19 in pregnant women at term. A vertical transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cannot be confirmed in this study, mainly because of the limited sample size and short timeframe between infection and birth.

Corresponding author: Claudia Florida Costea, Professor, MD, PhD; e-mail: costea10@yahoo.com; Catalin Mihai Buzduga, Lecturer, MD, PhD; e-mail: buzdugacatalin@yahoo.com

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12. Mechanism of the combined action of green tea polyphenols and concurrent radiochemotherapy in regulating GSK-3beta to treat non-small cell lung cancer through the Wnt/beta-catenin pathway

Kebei Xie, Yanli Wang, Zimin Chen

Green tea, derived from Camellia sinensis, contains polyphenolic active compounds that exhibit diverse pharmacological effects including anticancer, anti-inflammatory, antioxidant, and immunomodulatory properties. Employing various concentrations of green tea polyphenols (GTPs; 0, 100, 200, 300, 400, 500 micro-g/mL), human normal lung epithelial cells (BEAS-2B) and non-small cell lung cancer (NSCLC) cells (A549) underwent treatment. The cell viability was assessed using the cell counting kit-8 (CCK-8) assay, proliferation was examined through the colony formation assay, apoptosis was monitored via flow cytometry, cell migration, and epithelial-mesenchymal transition (EMT)-associated proteins (E-cadherin, N-cadherin) were determined by Western blot. A549 cells were subjected to Cisplatin (0, 0.5, 1, 1.5 microM) and X-ray irradiation (0, 2, 4, 6 Gy) for treatment to probe the influence of GTPs on A549 cells in response to chemoradiotherapy. The functioning mechanism of GTPs in the context of NSCLC was validated using lithium chloride (LiCl) [a glycogen synthase kinase-3 beta (GSK-3beta) inhibitor], which activates the Wnt/beta-catenin pathway. GTPs suppressed NSCLC cell viability in a concentration-dependent pattern, with a half-maximal inhibitory concentration (IC50) of 362.5 micro-g/mL, while showing little impact on BEAS-2B cells viability (at concentrations not exceeding 500 micro-g/mL). Treatment with GTPs dampened colony formation of NSCLC cells, while promoting apoptosis. LiCl treatment vigorously attenuated the inhibitory impact of GTPs on the malignant phenotype of NSCLC cells. Mechanistic studies suggested that GTPs strengthened GSK-3beta stability, thereby impeding the Wnt/beta-catenin pathway. Tea polyphenols (TPs) in conjunction with concurrent radiochemotherapy (CRCT) enhance the stability of GSK-3beta and dampen the Wnt/beta-catenin pathway, hence exerting anticancer effects in NSCLC.

Corresponding author: Zimin Chen, MD; e-mail: ziminchen653@outlook.com

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13. Odontogenic maxillary sinus disease: a cone-beam computed tomography surveillance

Paula Perlea, Cristina Coralia Nistor, Cristina Teodora Preoteasa, Irina Maria Gheorghiu, Oana Alexandra Mladin, Alexandru Andrei Iliescu

The odontogenic maxillary sinus disease (endo-antral syndrome; EAS) is directly related to the spread of endodontic infections from upper premolars and molars with necrotic pulp. Cone-beam computed tomography (CBCT) images proved to be a reference diagnostic aid for detecting the etiological relationship between chronic apical periodontitis and maxillary sinusitis. There were retrospectively evaluated a total of 109 CBCT images (47 males and 62 females) from a pool of CBCT scans taken for routine diagnosis and treatment planning in consecutive 353 patients. The CBCT images were acquired with Veraviewepocs 3D P (R100) equipment (J. Morita MFG Corp., Kyoto, Japan). The scan parameters were 90 kV, 5 mA, 9.4 s exposure time, 125 micro-m spatial resolution and 40x40 mm field of view (FoV). The aim of this CBCT study was to find out the influence of space separating apical lesions and sinus floor on subsequent EAS. There were observed four categories of anatomical rapports, such as tangent contact, protruding contact, 1-2 mm separating interval, and over 2 mm separating interval. The highest incidence was recorded in molars for tangent contact (47.69%) and in premolars when the apical lesions were situated at 1-2 mm distance from sinus floor (7.69%). The abnormalities revealed on CBCT scans of maxillary sinus have been mucosal hyperplasia, dome-shaped opacification, periostitis, and sinus opacification with air-bubbles. A four class classification related to the anatomical distance between the chronic apical lesions and sinus floor was suggested.

Corresponding author: Cristina Coralia Nistor, Assistant, DMD; e-mail: crisnistor78@gmail.com; Irina Maria Gheorghiu, Associate Professor, DMD, PhD; e-mail: igheorghiu@hotmail.com

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14. Unusual role in occlusion and mastication of a horizontal positioned erupted mandibular third molar: a rare case

Oana Cella Andrei, Gabriela Ciavoi, Liana Todor, Daniela Ioana Tarlungeanu, Livia Alice Tanasescu, Magdalena Natalia Dina

Lower third molars are frequently extracted due to pathologies of the dental follicle, pericoronitis, advanced carious lesions, orthodontic reasons (risk of anterior tooth crowding) or causing periodontal or carious lesions in the distal area of the second molar. The case presented here is of a male patient that came to our Clinic experiencing pain in the distal area of one of his old bridges. The clinical examination revealed a malpositioned, but unusually functional third molar; it is a very rare situation for an initially impacted third molar to erupt in an almost horizontal position and not only to remain on the arch for a very long period of time, but also to contribute to mastication efficiency and occlusion, despite the fact that masticatory forces are distributed at a right angle on its long axis and that mastication takes place on the distal surface of the crown and root, and not on the usually occlusal cusped surface. The horizontal mandibular right third molar contributed to maintaining the vertical dimension of occlusion and the masticatory efficiency for a very long period of time; it also ensured a proper distribution of forces trough the long axis of the second premolar, since the distal contact of the third s molar crown with the second premolar helped it to resist masticatory forces and to remain on the arch, despite the prolonged absence of any mesial contact.

Corresponding author: Liana Todor, Associate Professor, DMD, PhD; e-mail: liana.todor@gmail.com; Daniela Ioana Tarlungeanu, Assistant Professor, DMD, PhD; e-mail: ioanatarlungeanu@gmail.com

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15. Lymph node involvement in secondary breast angiosarcoma - a case presentation

Adriana Irina Ciuvica, Tiberiu Augustin Georgescu, Andrei Dennis Voichitoiu, Angela Arsene, Luchian Marinescu, George Ionut Bucur, Livia Iordache, Nahedd Saba

Angiosarcoma represents a group of rare tumors originating from vascular and lymphatic endothelial cells, characterized by marked aggressiveness, rapid growth and poor clinical outcome. The incidence of breast angiosarcoma accounts for approximately 0.05% of all malignant breast tumors and less than 1% of all sarcomas. In this article, we report the case of a 67-year-old female patient who presented to our Clinic due to a rapidly evolving, non-painful, vegetating mass, encompassing almost her entire left breast. Imaging studies revealed diffuse skin thickening in all quadrants and an intensely opaque axillary lymph node (LN). Interestingly, the patient had prior medical history of breast carcinoma treated conservatively in 2007 with limited breast resection and left axillary lymphadenectomy, followed by post-operative chemotherapy and radiotherapy. At the current presentation, we performed a radical mastectomy with ipsilateral lymphadenectomy. The histopathological examination revealed a secondary angiosarcoma with LN involvement mimicking an atypical vascular lesion. In this article, we report the clinicopathological particularities of this case and discuss the challenge of diagnosing LN involvement in angiosarcoma.

Corresponding author: Tiberiu Augustin Georgescu, MD, PhD; e-mail: tiberiuaugustin.georgescu@gmail.com

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16. Postoperative multiple perforations of the small bowel in a patient with COVID-19 - case report

Theodor Viorel Dumitrescu, Cristian Mesina, Mihai Calin Ciorbagiu, Luana-Corina Lascu, Sorina Octavia Hontaru, Nina Ionovici, Laurentiu Mogoanta, Stelian Stefanita Mogoanta

During the coronavirus disease 2019 (COVID-19) pandemic, the infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presented quite a diverse symptomatology, in addition to respiratory symptoms, while other clinical signs such as thrombosis, postoperative hemorrhages, acute kidney or liver failure, digestive disorders (vomiting and diarrheal stools) were also reported. We present the case of a patient diagnosed with transverse colon neoplasm and asymptomatic SARS-CoV-2 infection, who presented to the Emergency Room (ER) of the Emergency County Clinical Hospital, Craiova, Romania, with a clinical picture of low intestinal occlusion. Surgery was decided and a right hemicolectomy extended to the left, with terminal ileostomy performed. The postoperative evolution was favorable, with the resumption of intestinal transit and discharge on the third postoperative day. The patient returned to the ER Department on the fifth day after surgery, with diffuse abdominal pain, absence of intestinal transit and flatulence. Clinical examination of the abdomen revealed the presence of bloating sounds on palpation. Emergency laparotomy was again performed with the suspicion of postoperative occlusion and five perforations were found in the small bowel, associated with fecaloid peritonitis and mechanic-inflammatory occlusion. The perforations were without any obvious lesion substrate, four of them being located on the jejunum and one on the terminal ileum. The histopathological examination revealed hemorrhage and recent transmural thrombosis on the intestinal wall, most likely caused by COVID-19. Without any respiratory symptoms, the COVID-19 infection caused multiple intestinal lesions, leading to peritonitis and septic shock, followed by the patient s death.

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

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17. Nonimmune hydrops fetalis diagnosed at 35 weeks gestation - a case report

Liliana Anghelina, Mircea-Sebastian Serbanescu, Georgeta Ligia Stanescu, Cristian Gheonea, Mihail-Relu Stanescu, Mirela Anisoara Siminel

Nonimmune hydrops fetalis (NIHF) is a condition that can occur at any stage of pregnancy and is linked to a variety of disorders, resulting in severe perinatal complications and increased mortality risk. NIHF refers specifically to cases where maternal antibodies against red blood cell antigens are excluded. Early identification of the underlying causes is essential for managing pregnancy and deciding on treatment. The prognosis depends on the causes, both in the short and long term. Each case should be considered individually. We describe a case of severe fetal hydrops first identified at 35 weeks of gestation. In this instance, a definitive diagnosis could not be reached during pregnancy. An accurate diagnosis combined with early prenatal detection of NIHF is vital for reducing neonatal mortality associated with this condition.

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

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