ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 60 No. 4, 2019

1. Matrix metalloproteinases expression in lentigo maligna/lentigo maligna melanoma - a review of the literature and personal experience

Alice Brinzea, Roxana Ioana Nedelcu, Daniela Adriana Ion, Gabriela Turcu, Mihaela Antohe, Anastasia Hodorogea, Andreea Calinescu, Daniel Pirici, Raluca Popescu, Catalin Mihai Popescu, Cristiana Gabriela Popp, Luciana Nichita, Mirela Daniela Cioplea, Mariana Cordun, Sabina Andrada Zurac

Cutaneous melanoma is the most aggressive type of skin cancer, with high invasive potential. Lentigo maligna melanoma (LMM) is a relatively rare type, accounting for about 10% of all melanomas, while the most common subtype of melanoma on the face, typically on chronically sun-exposed skin of elderly people. Its in situ stage is lentigo maligna (LM). During the process of transformation from LM to LMM, tumor cells secrete or induce the release from neighboring cells of large amounts of matrix metalloproteinases (MMPs) that degrade the extracellular matrix. Some MMPs, as MMP3 and MMP9 expressed melanoma cells is associated with statistical significance in both in vitro and in vivo studies, with an invasive phenotype. Unfortunately, there is scarce data published about MMPs expression in LM/LMM, as majority of research on melanoma refer to superficial spreading and nodular melanoma. Our personal, unpublished yet fully data is an attempt to complete a specific panel of immunohistochemical markers that could explain the slow growing rate of LMM.

Corresponding author: Roxana Ioana Nedelcu, Assistant Professor, MD, PhD; e-mail: roxanaioana.nedelcu@yahoo.com

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2. Constant features of the adult maxillary bone in the site of the premaxillary suture: the sutura notha, Macalister s foramina, Parinaud s canal, and the second angle of the canalis sinuosus of Wood Jones

Mugurel Constantin Rusu, Monica-Mihaela Iacov-Craitoiu, Mihai Sandulescu, Laura Carstocea, Dan Mihail Stana

Developmental theories regarding the premaxillary (incisive) suture commonly overlook it separates the premaxillary and maxillary parts of the frontal process of maxilla. Thus, one would expect that neurovascular structures within this transitory mesenchymal zone to appear embedded within the adult frontal process of maxilla. The sutura notha (false suture, Weber s sutura longitudinalis imperfecta) is a poorly described, although constantly present, shallow groove in front of the anterior lacrimal crest, being perforated by a row of holes first described, to our knowledge, by Macalister, in 1884. Macalister s foramina should be discriminated anatomically from the accessory infraorbital foramina. Macalister s foramina lead into canals, usually described as vascular, within the frontal process. We demonstrate in cone-beam computed tomography that these canals, which correspond topographically to Parinaud s vascular canal, are connected, usually through a delicate intraosseous network, with Wood Jones canalis sinuosus (i.e., the ampullar angle of this canal located above the upper canine tooth). As this later carries the anterior superior alveolar nerve and artery, it is reasonable to consider that the canalar network within the frontal process of maxilla could serve for an accessory distribution of that nerve to the nasolacrimal duct, the atrium of the middle nasal meatus, the agger nasi cell, as well as to the infraorbital (prelacrimal) recess of the maxillary sinus.

Corresponding author: Monica Mihaela Iacov-Craitoiu, Associate Professor, DMD, PhD; e-mail: mcraitoiu@yahoo.com

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3. Cardiovascular anomalies and evolutionary risk factors in schizophrenia - multifactorial approach

Liana Dehelean, Ileana Marinescu, Puiu Olivian Stovicek, Minodora Andor

Schizophrenia is a functional psychosis with a multifactorial etiopathogeny involving genetic, endocrine and immunological risk factors. The main pathogenic hypothesis involves dopamine dysregulation, with hyperfunction in the limbic system and hypofunction in the prefrontal cortex. Normal dopamine activity is critical for cognitive and emotional processing, but also for autonomic and immune regulation. Co-morbidity between schizophrenia and cardiovascular anomalies is complex. Genetic factors influence the development of brain, cardiac and vascular structures, as well as the activity of enzymes involved in dopamine synaptic turnover. Autoimmunity triggered by infections or related to systemic diseases affects both brain and heart in a direct manner through autoantibodies and/or indirectly through microvascular injury. In most cases, the co-morbidity between schizophrenia and cardiac diseases is secondary to metabolic dysfunctions induced by psychotropic medication or psychosis itself. Because of their diverse pharmacodynamic profiles, antipsychotics differ in their propensity to facilitate the development of the metabolic syndrome. The distress associated with acute psychotic symptoms or a sedentary lifestyle due to negative symptoms may have a negative impact on the energetic metabolism or cardiac function. Conclusions: An interdisciplinary approach is required between neurosciences and cardiology not only at the research level, but also in the clinical practice. Cardiac co-morbidity in subjects with schizophrenia may critically affect the survival rates of these patients. Moreover, the nature of the cardiac co-morbidity may guide the clinician in better understanding and differentiating functional psychoses from organic ones. The multifactorial approach can identify cardiovascular risk factors based on clinical, biological and neuroimaging markers.

Corresponding author: Ileana Marinescu, Lecturer, MD, PhD; e-mail: marinescu_psy@yahoo.com

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4. New insights in the molecular pathways linking obesity, type 2 diabetes and cancer

Adina Popa, Milena Georgescu, Simona Georgiana Popa, Adriana Elena Nica, Eugen Florin Georgescu

Steadily, cancer is becoming the first cause of mortality, with over 9 million deaths estimated in 2018. Increasing evidence supports a direct association between obesity, type 2 diabetes mellitus (T2DM) and cancer, with a higher risk of cancer mortality especially for some of the most common malignancies, such as breast, colon, and rectal cancers. So far, several mechanisms underlying the cancer-diabetes relationship have been investigated revealing dysregulations of the insulin-insulin-like growth factor (IGF) system as the most important paradigm. Other molecular mechanisms that seem to play a role in the association cancer-T2DM consist of alteration of the signaling pathways activated by inflammatory cytokines, adipocytokines or adhesion molecules. The overall aim of this review is to provide an overview of the molecular mechanisms linking obesity, T2DM and cancer, as related to the receptors and signaling pathways involved in these associations.

Corresponding author: Simona Georgiana Popa, Associate Professor, MD, PhD; e-mail: geossim@yahoo.com

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5. Bone turnover markers in postmenopausal osteoporosis and their correlation with bone mineral density and menopause duration

Camelia Vidita Gurban, Melania Olga Balas, Mihaela Maria Vlad, Alexandru Emil Caraba, Adelina Maria Jianu, Elena Silvia Bernad, Claudia Borza, Simona Banicioiu-Covei, Andrei Gheorghe Marius Motoc

Background: Biochemical bone turnover markers (BTMs) estimates the bone remodeling process, being valuable in the personalized approach of osteoporotic patients. Aim: The aim of the study was to evaluate the correlation between biochemical BTMs and bone mineral density (BMD), depending on menopause period, in postmenopausal osteoporotic women, compared to postmenopausal women without osteoporosis. Patients, Materials and Methods: The study included 149 untreated postmenopausal women, divided into three groups: group 1 (65 osteoporotic women with less than 10 years of menopause), group 2 (44 osteoporotic patients, with over 10 years of menopause), and the control group with 40 postmenopausal women without osteoporosis. Results: All BTMs levels were higher in the groups with osteoporosis, than in the control group. Lumbar BMD values correlated positively with deoxypyridinoline (DPD) and negatively with bone-specific isoform of alkaline phosphatase (BAP), tartrate-resistant acid phosphatase band 5b (TRAP 5b), osteocalcin (OC) and cross-linked N-telopeptides of type I collagen (NTX). Serum estradiol levels correlated positively with spine BMD in the whole study group (r=0.508, p=0.001). BTMs correlated positively with each other. Osteoporotic women with longer period of menopause presented significantly higher values of resorption markers (NTX and TRAP 5b), compared to the group with menopause duration less than 10 years. At a cutoff value of 12 micro-g/L, BAP presented 82.4% sensitivity and 62.5% specificity. Conclusions: Our study showed that BTMs correlated negatively with lumbar BMD and positively with each other. Resorption markers levels increase with duration of estradiol deprivation period.

Corresponding author: Adelina Maria Jianu, Associate Professor, MD, PhD; e-mail: adelina.jianu@gmail.com

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6. Evaluation of iNOS -2087A>G polymorphism in recurrent pregnancy loss

Lidia Boldeanu, Anda Lorena Dijmarescu, Marius Bogdan Novac, Luciana Teodora Rotaru, Vlad Padureanu, Simona-Daniela Neamtu, Cristian Adrian Silosi, Cristiana Geormaneanu, Mihail Virgil Boldeanu, Isabela Silosi, Liliana Victoria Novac

Background: Due to its role in angiogenesis, the inducible nitric oxide synthase (iNOS) gene promoter polymorphism may have a presumed role in recurrent spontaneous abortions (RSA). It is an intensely studied protein, a biological mediator, a modulator and an effector molecule by implication in numerous physiological processes: vasodilatation, angiogenesis, immunity, tissue remodeling, smooth muscle activity. Aim: Our study aims to investigate a possible association between iNOS -2087A>G (rs2297518) polymorphism and the occurrence of idiopathic recurrent pregnancy loss (RPL). Patients, Materials and Methods: In this study, as in the previously published one, 169 women, diagnosed with RPL, in the Clinics of Obstetrics and Gynecology, Filantropia Municipal Hospital, Craiova, Romania, were subjected to the analysis, from October 2009 to October 2016. As a control group, we used 145 women. Subjects from both groups were genotyped using specific probes for TaqMan polymerase chain reaction (PCR), allelic discrimination technique. Results: We evaluated in this study a possible association between iNOS -2087A>G (rs2297518) polymorphism and the occurrence of idiopathic RPL. The chi-square test showed no significant association between the presence of this polymorphism and the increased risk to develop RPL. When we performed a comparative analysis of the frequency of genotypes and our statistical data, it was observed that this polymorphism, iNOS -2087A>G (rs2297518), has not been associated with an increased risk of developing RPL. Also, when one genotype was compared with another, we did not obtain any association that would have statistical significance, between the presence of this polymorphism and the increased risk for patients to develop RPL [in dominant - A allele carriers, iNOS 2087 AG+AA vs. GG: odds ratio (OR) 1.31, 95% confidence interval (CI) 0.83-2.07, p=0.24]. Analyzing the overall risk of developing RPL by iNOS 2087 single-nucleotide polymorphism (SNP) genotype frequencies, between controls and RPL patients (which were stratified by number of consecutive PLs), taking into account the number of consecutive pregnancies, the chi-square test showed no association between the presence of this polymorphism and the increased risk for developing RPL in all three subgroups we analyzed (in a dominant model - A allele carriers, iNOS 2087 AG+AA vs. GG: the first subgroup, OR 1.31, 95% CI 0.83-2.07, p=0.24; the second subgroup, OR 1.26, 95% CI 0.76-2.11, p=0.37; the three subgroup, OR 1.4, 95% CI 0.77-2.53, p=0.272). Conclusions: The iNOS -2087A>G (rs2297518) gene polymorphism does not influence RPL in the study area of Dolj County, Romania.

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

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7. Correlations between histological subtypes and neurocognitive assessment of language area tumors. Our 43 case series and review of the literature

Mihaela Cosman, Ionut Mihail Pantiru, Roxana Serban, Lucia Indrei, Nicoleta Dumitrescu, Irina Raileanu, Mirela Iulia Aldea, Ana Maria Dumitrescu, Ion Poeata

Background: Brain tumor location is related with specific, focal neurological impairment, but also with more diffuse, generalized and subtitle neurocognitive dysfunctions. For a better evaluation of these cases, we need a specific battery of tests. Beside the impact of preoperative status on surgical decision, the quantification of postoperative function alteration is essential in neurorehabilitation. Patients, Materials and Methods: We proposed a battery of tests to assess the neurocognitive function, with an accent on language adapted to Romanian population. The 43 cases included in the study were tested preoperatively, seven days postoperatively and at one month, and correlated with the images and histological results. Results: At admission, from all participants, 11.6% were affected across all measured items and 6.9% on none of them. A rate of impairment significantly higher, four or more items, was observed in glioblastoma (GB) cases (23.3%) in contrast with low-grade glioma (LGG) (0%), meningioma (0%) and metastases (6.9%). From all cases, we performed seven awake craniotomies. At one-month evaluation, general decrease in neurocognitive function was observed in 20.93% cases, among them 88.88% being GB and favorable outcome in 32.55% patients with dominance of LGG and meningioma cases. Conclusions: A neurocognitive assessment of brain tumor patients is important for preoperative and postoperative evaluation and secondary adjustment of the surgical resection in order to improve or, at list, meantime the initial status. The role and the link between the histological type and tests alteration were observed. The results can be used for a better understanding and management of language area tumors.

Corresponding author: Roxana Serban, MD, PhD Student; e-mail: roxana_serban10@yahoo.com; Mihaela Cosman, MD, PhD Student; e-mail: mihaelacosman@yahoo.com

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8. Lung injury patterns in newborns, infants and young children - morphological and immunohistochemical approaches

Cornelia Titiana Cotoi, Sabin Gligore Turdean, Mihai Lazar Turcu, Ovidiu Laurean Pop, Dragos Florin Baba, Cristina Oana Marginean, Corneliu Florin Buicu, Daniela Lucia Muntean

Lower respiratory infections are an important cause of morbidity and mortality in children, especially in newborns, infants and young children. We conducted a retrospective study and we analyzed the causes of death in newborns, infants and young children, in the necropsy protocols from two Departments of Pathology (Mures County Hospital and Emergency County Hospital of Targu Mures, Romania), between 2016-2018. We performed descriptive statistics: number of necropsies per year, distribution by gender (male/female), by place of origin (rural/urban), by age and leading causes of death in our study. To establish the pattern of lung injuries, we performed a morphological, histopathological and immunohistochemical study [cluster of differentiation (CD) 3, CD14, CD20, CD31, CD34, CD68]. Our study is showing the most frequent and typical aspects of pulmonary pathologies in fetuses, newborns, infants and young children. In this way, we are highlighting the microscopic aspects of the immature lung, amniotic fluid and meconium aspiration, pulmonary distress syndrome in children, pneumonia, bronchopneumonia and vascular pulmonary disease developed in patients with congenital cardiac defects. Most deaths were recorded in the first 30 days or in the first year of life. Primary respiratory diseases were the leading causes of death in these patients. Secondary respiratory diseases were associated with the major causes of death in these patients as an aggravating or precipitating factor.

Corresponding author: Sabin Gligore Turdean, MD, PhD; e-mails: sabin.turdean@umfst.ro, sabiturdean@yahoo.com

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9. Serological and immunohistochemical biomarkers for discrimination between benign and malignant ovarian tumors

Anda Lorena Dijmarescu, Veronica Gheorman, Maria Magdalena Manolea, Sidonia Catalina Vrabie, Maria Sidonia Sandulescu, Cristian Adrian Silosi, Isabela Silosi, Mirela Radu, Mircea Vasile Popescu-Driga, Marius Bogdan Novac, Vlad Padureanu, Anca-Maria Istrate-Ofiteru, Lidia Boldeanu

Background: Ovarian tumors are difficult to diagnose because symptoms are nonspecific, occurring in late stages when the tumor mass reaches large proportions, when complications arise or when dissemination occurs in neighboring organs. Research over the past decades has been aimed at clarifying the mechanisms of ovarian oncogenesis, to identify ways of transforming normal cells into a neoplastic cell, as well as discovering of tumor markers used in the detection of neoplastic processes, along with the synthesis of therapeutic substances, which would influence its development. Aims: In our study, we aimed to determine the serum concentrations of cancer antigen 125 (CA125), human epididymis protein 4 (HE4) and the risk of ovarian malignancy algorithm (ROMA) in patients with ovarian tumors, as well as assessing their diagnostic performance. Furthermore, another objective of the study was to identify a concordant relation between serological and immunohistochemical (IHC) biomarkers in supporting and aiding the differentiation between benign and malignant tumors, here including the group of borderline tumors. Patients, Materials and Methods: We accomplished a study that included a group of 92 patients diagnosed with ovarian tumors (benign and malignant), who were examined and treated between January 2015 and July 2018. The study was conducted at the Clinics of Obstetrics and Gynecology, Filantropia Municipal Hospital of Craiova, Romania. The patients were divided into two groups: the group of patients with benign tumors, subdivided into pre-menopausal (51 cases, 55.43%) and post-menopausal (30 cases, 32.6%) patients, and a group of patients who presented with malignant formation (seven cases with malignant tumors, 7.61% and four cases with borderline tumors, 4.34%, respectively). In parallel, we investigated 35 women as control subjects, who did not have a personal history of ovarian tumors. Results: In our study, we have observed that for the analyzed parameters, CA125, HE4, and the ROMA index, significantly higher serum concentrations were detected in the malignant tumor group, when these have been compared to the values obtained for the pre-menopausal and for the post-menopausal subgroup, respectively. The IHC results also showed different expression patterns for the different markers studied. Corroboration of the results of the serological biomarkers with the IHC data is necessary and useful for differentiating borderline tumors and for their final integration as benign or malignant ovarian tumors. This can only be done for the cases with surgical resections, thus having tissue available. Conclusions: The serum levels of CA125 and HE4, ROMA index and IHC markers for surgical tissue fragments play a very important role in discriminating and reporting borderline ovarian tumors, as well as benign or malignant ovarian forms. Due to the superior sensitivity and specificity of CA125 and HE4, we can consider these markers as an alternative or additional diagnostic criterion to the ROMA index.

Corresponding author: Anca-Maria Istrate-Ofiteru, MD; e-mail: ancaofiteru92@yahoo.com; Vlad Padureanu, Teaching Assistant, MD, PhD; e-mail: vldpadureanu@yahoo.com

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10. Pelvic exenteration, a surgical treatment option for locally advanced, primary and recurrent neoplasia

Ana-Maria Musina, Ionut Hutanu, Mihaela Grigore, Ioana-Shadiye Scripcariu, Bogdan Filip, Maria-Gabriela Anitei, Dragos-Viorel Scripcariu, Mihaela-Madalina Gavrilescu, Iulian Radu, Nicolae Ioanid, Adrian Nicolae Pantazescu, Maximilian Hogea, Andrian Panuta, Mihaela Buna-Arvinte, Gianina-Vanda Moraru, Viorel Scripcariu

Pelvic exenteration (PE) is an extensive surgical procedure for locally advanced primary neoplasia (LAPN) or recurrent neoplasia (RN) that consists in the en bloc removal of the pelvic organs (rectum, internal genital organs and bladder) associated with pelvic lymph nodes. PE is classified into anterior, posterior and total, supra or infralevatorian approaches. Our aim was to evaluate the surgical procedure and the resection margins in correlation with postoperative complications and morbidity rates after PE in patients treated in a single surgical unit. The study group comprised patients diagnosed with different malignancies, surgically treated by using PE procedure, during 2012-2018. The cohort included 121 cases with LAPN (n=98, 80.99%) and RN (n=23, 19%), mostly female (n=114, 94.21%), with a mean age of 61.16 (33-85) years. LAPN had predominantly digestive (n=48, 49.98%) and gynecological (n=28, 28.57%) origins, while the majority of RN cases were cervical cancers (n=9, 39.13%). The univariate analysis showed that the gynecological origin of the tumor (p=0.02), urinary stoma (p=0.02) and posterior PE (PPE) (p=0.004) were significant prognostic factors for postoperative complications. After performing the multivariate analysis, only the gynecological origin (p=0.02) of the tumor and PPE (p=0.03) remained determining factors for postoperative complications. PE is a disabling surgical procedure associated with high postoperative mortality and morbidity, although it is often the only solution for advanced cases. The judicious selection of patients who can benefit from such extensive surgery is compulsory. Our study suggests that the gynecological origin of the tumor and PPE are key factors in postoperative complications.

Corresponding author: Ionut Hutanu, Assistant Professor, MD, PhD; e-mail: hionut65@gmail.com; Mihaela Grigore, Associate Professor, MD, PhD; e-mail: mihaela.grigore@edr.ro

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11. Histopathological predictive factors for the overall survival rate in patients with urothelial carcinoma of the bladder treated by radical cystectomy: a Romanian cohort study

Ioan Alin Nechifor-Boila, Bogdan Calin Chibelean, Andrada Loghin, Adela Corina Nechifor-Boila, Toader Septimiu Voidazan, Maria Flavia Radulescu, Angela Borda

Introduction: Urothelial carcinoma (UC) variants are considered as having a more aggressive behavior and a more advanced stage at presentation than conventional UC. However, the evidence supporting the role of UC variants on overall survival (OS) is conflicting. We aimed to assess the impact of demographic factors (age at surgery, gender) and tumor characteristics [conventional/variant UC, associated carcinoma in situ (CIS), associated papillary component, Tumor, Node, Metastasis (TNM) staging, positive surgical margins] on OS in a series of patients treated for UC in our Department. Patients, Materials and Methods: We performed a retrospective, cohort study and included 69 UC patients treated by radical cystectomy (RC) in our Department over an eight-year period, with complete follow-up information. Associations of UC variants as well as demographic and morphological factors with OS were assessed using univariable and multivariable Cox analysis. Results: Our data showed that UC variants were statistically significantly associated with the presence of distant metastases (p=0.036) and positive surgical margins (p=0.009), but had no influence on OS (p=0.504). Further on, we demonstrated that age at surgery (p=0.045), tumor stage (p=0.012), lymph node involvement (p=0.009), and presence of positive surgical margins (p=0.002) had a statistically significant influence on OS both by univariable and multivariable Cox analysis. Conclusions: Age, tumor stage and lymph node involvement, as well as positive surgical margins represent prognostic factors in RC patients. UC variants were more likely to be associated to metastases and positive surgical margins but had no influence on OS.

Corresponding author: Bogdan Calin Chibelean, Lecturer, MD, PhD; e-mail: calinchibelean@yahoo.com

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12. Clinical, statistical, histological and immunohistochemical aspects of periodontal changes in patients with diabetes mellitus

Cristina-Mihaela Farcas-Berechet, Elena-Magdalena Berechet, Stefania Craitoiu, Mihaela-Cezarina Mehedinti, Andrei Osman, Irina-Anca Eremia, Cristina Popescu, Monica-Mihaela Iacov-Craitoiu

Background: Both diabetes mellitus (DM) and periodontal disease are the most widespread chronic inflammatory diseases that affect a very large number of the population worldwide. Aim: This study s aim was to compare the status of dental hygiene in a group of patients with DM, with patients in the control group, and to histologically analyzing the gum from the subjects with DM. Patients, Materials and Methods: The study sample was made up of 53 control subjects and 107 diabetics aged 19-80 years old. We evaluated the following parameters: the plaque index (PI) and the calculus index (CI), according to Simplified Oral Hygiene Index, and the gingival index (GI), according to the Loe and Silness criterion, correlated with glycosylated hemoglobin and the blood sugar levels. Results: For all hygiene indices, the mean values recorded for the control group were significantly lower than the mean values recorded for any sub-category in the diabetic groups. Conclusions: DM contributes unfavorably to the evolution of periodontal disease. The poor glycemic control and the improper oral hygiene have a negative impact on the health of the periodontium, highlighted by increased scores on PI, CI and GI scales.

Corresponding author: Stefania Craitoiu, Professor, MD, PhD; e-mail: scraitoiu@yahoo.com; Cristina Popescu, Assistant Professor, MD, PhD; e-mail: cristina.popescu25@yahoo.com

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13. Head and neck metachronous tumors - clinical, histopathological and immunohistochemical study

Ion Cristian Mot, Marioara Poenaru, Carmen Aurelia Mogoanta, Anca-Maria Istrate-Ofiteru, Ioana Cristina Opriscan, Cristian Andrei Sarau, Marina Daniela Manescu, Viorela Enachescu, Carmen Adriana Dogaru, Cristina Popescu, Raluca Morar, Nicolae Constantin Balica, Ioana Delia Horhat

Multiple primary tumors (MPT) represent an important factor affecting the survival of some patients. They present an incidence of about 0.7-11% of all carcinomas developing in any region of the human body, being either synchronous or metachronous. These tumors raise problems of differential diagnosis, with tumoral relapses and distance metastases; also, they involve problems related to chemotherapy, radiotherapy and surgical treatment. In the present paper, we studied a group of 902 patients diagnosed with head and neck tumors admitted to the Ear, Nose and Throat (ENT) Clinic of the Emergency County Hospital of Timisoara, Romania, and we identified 12 patients with metachronous tumors, representing 1.33% of the hospitalized cases. Of the 12 patients with metachronous tumors, a single case was a woman, the other 11 cases being diagnosed in men. Regarding the age of the patients with metachronous tumors, only a single patient was aged less than 60 years old; most of them (nine patients) were aged between 60 and 69 years old, while two patients were aged over 70 years old. Nine patients were alcohol consumers, while 10 (83.33%) patients were smokers of about 20 cigarettes/day. All the metachronous tumors localized in the head and neck were squamous cell carcinomas. The second primary tumor was identified in the prostate, kidneys, ureter, lungs, salivary gland, thyroid gland, meninges, colon, rectum or skin.

Corresponding author: Carmen Aurelia Mogoanta, Lecturer, MD, PhD; e-mail: carmen_mogoanta@yahoo.com; Cristian Andrei Sarau, Lecturer, MD, PhD; e-mail: csarau@gmail.com

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14. Malignant melanoma - the most severe skin cancer and neurological pathology

Anca Ioana Motataianu, Maria Smaranda Maier, Laura Chinezu, Laura Iulia Barcutean, Toader Septimiu Voidazan, Zoltan Bajko, Adrian Florian Balasa

Objective: We report our clinical experience with malignant melanoma (MM) patients associated with neurological involvement. Patients, Materials and Methods: A database of patients admitted from 2014-2019 in the Ist Clinic of Neurology, Emergency County Hospital of Targu Mures, Romania, was reviewed to identify patients with MM and neurological involvement. We assessed the demographic and clinical data regarding the neurological disorders and the primary tumor characteristics from the patient registries. Both histopathological and immunohistochemical analysis of the neoplasm was available for the entire cohort. Results: We analyzed 13 982 patient files and 21 met all the inclusion and exclusion criteria. Brain metastases were found in 38.09% of the patients, spinal metastases in 9.52% of the patients, ischemic stroke by cancer-associated thrombosis in 42.85% of the patients and peripheral nervous system involvement in 19.04% of the patients. No statistically significant differences between the four categories of neurological disorders according to socio-demographic parameters, location of the primary tumor, existence of primary tumor ulceration, invasion of the lymph nodes or the presence and location of distant metastasis was found (p>0.05). Our presented patient is the first case of uveal melanoma with hemorrhagic brain metastasis before hepatic involvement. Conclusions: Neurological involvement in MM encompasses a myriad of variants and while the clinical setting varies from one patient to another, an underlining neoplasia should be evaluated in suspected patients.

Corresponding author: Maria Smaranda Maier, Assistant Lecturer, MD, PhD; e-mail: maier_smaranda@yahoo.com

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15. Immunoexpression of E-, P- and N-cadherins in ovarian serous malignant tumors

Corina Maria Dochit, Alex Emilian Stepan, Claudiu Margaritescu, Mirela Marinela Florescu, Cristiana Eugenia Simionescu

Alteration of cadherin immunophenotype is associated with the epithelial-mesenchymal transition, a complex biomolecular mechanism involved in carcinomas progression. The study investigated the immunoexpression of E-, P- and N-cadherins in 50 serous malignant tumors of ovary related to the histopathological prognostic parameters of the lesions, using a quantification based on scores that took into account the number of marked cells and the intensity of the reactions. The E-cadherin and P-cadherin immunostainings were significantly superior in serous borderline tumors (SBTs) compared to carcinomas, as well as in advanced carcinomas compared to early stages. Although the immunoreactions indicated higher scores in high-grade serous carcinomas (HGSCs) versus low-grade ones (LGSCs), the aspect was without statistical significance. Immunoreactions of N-cadherin were present only in HGSC, being significantly superior in the advanced stages of tumors. Ovarian serous malignant tumors expressed E-, P- and N-cadherins in different proportions, the altered cadherin phenotype being associated with progression of the disease. The results can be used to identify tumors with progression potential and to better stratify patients for specific therapy.

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

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16. Congenital anomalies of digits - a clinical-epidemiological study of 301 patients

Maria Claudia Jurca, Marius Bembea, Mircea Ioan Sandor, Dana Carmen Zaha, Rodica Anamaria Negrean, Cosmin Mihai Vesa, Aurora Alexandra Jurca, Florentina Corina Moisa, Laura Gratiela Vicas, Corina Paul, Simona Diana Cheregi, Ariana Szilagyi, Camelia Liana Buhas, Alexandru Daniel Jurca

Introduction: Congenital anomalies of digits (CAD) can occur as isolated malformations, in combination with other malformation of the limbs, or as part of a genetic syndrome. The purpose of this work is to provide an overview of CAD, on morphological, genetic and epidemiological basis. Patients and Methods: We conducted a retrospective analysis of a cohort of 301 patients with CAD. Following the Swanson classification, the list of anomalies under study included: adactyly and oligodactyly, syndactyly and symphalangism, polydactyly, macrodactyly, amniotic bands syndrome, and generalized skeletal anomalies. Results: In Bihor County, Romania, the Department of Medical Genetics recorded 4916 patients with congenital anomalies (2.03% out of 241 601 live newborns) between 1984 and 2018. Of these, 301 (6.1%) patients had CAD. The prevalence of CAD was 1:800 living newborns. The most common CAD were polydactyly, followed by syndactyly, brachydactyly, adactyly and oligodactyly. Upper extremities were four times more frequently affected than lower extremities, while both upper and lower extremities were affected in a quarter of all cases. CAD were isolated in 64% of patients, while 14% were associated with other anomalies of the extremities and 22% were associated with recognized genetic syndromes. Conclusions: Our study, by its size and the long period of clinical observation, provides opportunities to generalize and compare our data with similar studies, offering the possibility for improved knowledge of the epidemiology of CAD and potential improvements in genetic counseling.

Corresponding author: Maria Claudia Jurca, Lecturer, MD, PhD; e-mail: claudiajurca70@yahoo.com; Marius Bembea, Professor, MD, PhD; e-mail: bembea13@yahoo.com

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17. Retrospective study regarding the appearance of osteonecrosis related to bisphosphonate therapy

Adela Cristina Lazar, Roxana Socaciu, Ovidiu Muresan, Mariana Pacurar

Bisphosphonates are analogues of the natural compound pyrophosphate and one consequence of the mechanism of action of bisphosphonates on bone metabolism is the reduction of bone turnover, replenish the resorption spaces and to mineralize the extracellular matrix. Osteonecrosis of the jaw is the most common side effect of bisphosphonates and most often occurs after an invasive dental procedure, such as dental extraction. The existence of a maxillary bone infection leads to a delayed healing reaction manifested by the presence of areas necrotic bone, exposed in the oral cavity, which persists for more than eight weeks and has no tendency to heal. In most cases, the dentist is the first one who can detect the onset of osteonecrosis even in the early stages, thus being able to direct the patient to a hospital unit where he/she receives the treatment of necessity. The aim of this retrospective study is to determine the link between bisphosphonate therapy and the occurrence of necrosis of maxillary and mandibular bone. This study was conducted on 22 patients hospitalized for different stages of bone necrosis for a period of two years. The prevalence of osteonecrosis is higher in menopausal women and also after a certain period after the bisphosphonate therapy is closed.

Corresponding author: Adela Cristina Lazar, Assistant Professor, DMD, PhD; e-mail: lazar_adela@yahoo.ro

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18. Polymorphism of clinical manifestation of HPV infection in the genital mucosa - 3-year retrospective study

Mihaela Mitrea, Allia Dmour, Loredana-Liliana Hurjui, Ciprian-Gavrila Ilea, Irina-Liviana Stoian, Simona Niculescu

Background: Human papillomaviruses (HPVs) are associated with a wide variety of cutaneous and mucosal infections and with malignancies in humans. More than 100 HPV types have been identified, some of which have affinity for skin and others for mucosal sites. Aim: The purpose of this study came from our desire to support the Stop Cervical Cancer campaign, adopted as Cervical Cancer Removed as a Public Health Problem, following the World Health Organization (WHO) initiative in 2019-2020. At European level, cervical cancer mortality has fallen by more than 30% over the past 30 years, through coherent, consistent and comprehensive prevention programs based on accurate and consistent public information. Romania is in an unfavorable situation with regard to incidence (32.8 new cases/100 000 women) and cervical cancer mortality (10.9 deaths/100 000 women). Free Babes-Papanicolau (Pap) testing for early detection of cervical cancer was valid this year until March. Patients, Materials and Methods: The study runs over a period of three years, between 2016-2018, in the Elena Doamna Hospital of Obstetrics and Gynecology, Iasi, Romania. Of the 8500 patients hospitalized for various diseases (ovarian cysts, uterine fibroids, endometriosis, abnormal vaginal bleeding, dysmenorrhea, ectopic pregnancies, placenta praevia, spontaneous abortions and on demand, benign, malignant tumors), only 382 were present in the ambulatory for Pap test. For the other conditions, Pap test denied because the patients did not want this but to solve the condition for which they presented themselves. Results: We retrospectively review 382 Pap tests of patients who presented themselves in the Ambulatory Service of the Hospital both at the advice of the gynecologist and due to the program initiated by the WHO and supported by the Department of Public Health, Iasi: Cervical cancer can be eliminated as a problem of public health. Lesions equal to or worse than high-grade squamous intraepithelial lesion (HSIL) equivalate with high-grade lesions including HSIL (cervical intraepithelial neoplasia - CIN1, CIN2). Endometrial lesions were excluded from the study. As seen of this campaign, the number of patients has increased in 2018 (242 cases), compared to 46 cases in 2017 and 94 cases in 2016. Conclusions: Our study demonstrated that 35% (7/20) of HSIL-confirmed biopsies previously had negative HPV assays. Despite the previous negative HPV tests, a wide variety of HPV genotypes has been detected in most biopsies. In our case, we frequently identified the HPV 59 and 45 strains, 51 cases with HSIL lesions presented a first positive HPV test, 13 cases with low-grade squamous intraepithelial lesion (LSIL) showed three negative HPV tests. Prevention plays an important role in reducing the incidence of cervical cancer cases. The Pap test is now considered the primary prevention method, but consecutive vaccination significantly increases protection against high-risk HPV strains. Education plays an important role in the prophylaxis of HPV infection and cancer. It should be instituted in schools, from puberty age through partnerships or government programs with public health directorates and university hospitals or using European funds.

Corresponding author: Ciprian-Gavrila Ilea, MD; e-mail: cilea1979@yahoo.com; Irina-Liviana Stoian, MD; e-mail: stoian.irinav@yahoo.com

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19. Prognostic significance of E-cadherin expression in hepatocellular carcinoma: correlations with clinical features

Amadeus Emanuel Dobrescu, Simona Norina Basa, Marioara Cornianu, Daniela Cornelia Lazar, Silviu Cristian Suciu, Anca Tudor, Octavia Cornelia Vita, Dorin Cristi Tarta-Marcu, Robert Alexandru Barna, Octavian Fulger Lazar

Background: Hepatocellular carcinoma (HCC) represents a major public health issue, being associated with high morbidity and mortality rates. Previous studies have demonstrated that reduction and/or absence of E-cadherin expression is correlated with a potential for invasion and low survival rate in patients with HCC. Patients, Materials and Methods: We assessed the immunohistochemical expression of E-cadherin in 32 HCCs and peritumoral hepatic tissues using monoclonal anti-E-cadherin antibody (clone EP700Y), at 1:50 dilution, followed by incubation with Labeled Streptavidin-Biotin 2 (LSAB2) for 20 minutes, visualization of the reaction with 3,3-Diaminobenzidine (DAB) and counterstaining with Mayer s Hematoxylin. Results: The results we obtained show: an aberrant E-cadherin expression more frequent in dysplastic nodules (p=0.285) and in 81.25% of HCC cases, as compared to normal hepatic tissue (p<0.001); the absence of a statistically significant relationship between E-cadherin expression and patients gender (p=0.854), tumor localization (p=0.429), associated viral infection [hepatitis B virus (HBV) or hepatitis C virus (HCV)] (p=0.513) or tumor size (p=0.788); the rate of positive E-cadherin expression was significantly higher in tumors with capsular infiltration (75%) (p=0.017) and does not appear to be influenced by vascular invasion (62.5%) (p=0.411), the presence of satellite nodules (p=0.285) or the serum level of alpha-fetoprotein (alpha-FP) (p=0.787). Conclusions: Reduced E-cadherin expression indicates a poor prognosis for patients with HCC and can be considered a potential predictive marker for the prognosis of these patients.

Corresponding author: Simona Norina Basa, Assistant Professor, MD, PhD; e-mail: norina.basa@yahoo.com; Marioara Cornianu, Associate Professor, MD, PhD; e-mail: marioaracornianu@yahoo.com

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20. Clinico-pathological study of chronic rhinitis in adolescents

Rebecca Cristiana Serban, Elena Loredana Selaru, Mioara Desdemona Stepan, Florentina Dumitrescu, Alex Emilian Stepan, Georgeta Ligia Stanescu, Elena Carmen Niculescu, Cristian Gheonea

Through the increasing incidence and association of asthma, chronic rhinitis (CR) raises major problems in the pathology of children and adolescents. The evaluation of the inflammatory status together with the diagnosis and the tandem treatment of the two conditions can contribute to the improvement of the patients quality of life. In this study, we analyzed the immunoexpression of cluster of differentiation (CD) 20, CD8, CD138 and eosinophil major basic protein (MBP) in 24 cases of CR in adolescents, in eight of them existing the association of asthma. Symptoms of CR and allergic status, as well as histopathological changes specific to a persistent inflammation, were identified in this study. The CD20/CD8 immunophenotype was more specific for CR, while the CD138/eosinophil MBP immunophenotype was specific for asthma-associated chronic rhinitis (AACR). The negative linear distribution of lymphocyte elements compared to plasmocytes and eosinophils specific for the allergic status can support the protective effect of CD8 T-lymphocytes and the presence of a semi-activated B-lymphocyte status in CR. The results may be useful for improving the stratification criteria of patients for therapy.

Corresponding author: Mioara Desdemona Stepan, Teaching Assistant, MD, PhD; e-mail: dstepan80@yahoo.com; Florentina Dumitrescu, Lecturer, MD, PhD; e-mail: dumitrescu_florentina@yahoo.com

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21. Basal cell carcinoma of the nasal pyramid excision margins: a retrospective study

Ivan Vatamanesku, Sorin Viorel Parasca, Otilia Maria Parasca, Florin Alexandru Vaida, Mihaela-Cezarina Mehedinti, Florin Grosu, Marius Eugen Ciurea

Basal cell carcinoma (BCC) is the most frequent skin cancer and its location in the nasal pyramid poses treatment problems. The main issue is how large the resection margins should be. The article presents a retrospective study on patients with BCCs of the nose. Thirty-seven patients were included and the correlations between incomplete resections and tumor dimensions, resection margins or histological sub-type were investigated. Of the 37 patients, only five had tumor-positive excision margins, but no correlation with the above-mentioned factors could be found. An overall tendency to over-resection was detected, contrary to the tendency depicted in the literature, but the incomplete resection rate (13.5%) is comparable with other reports. Further studies are needed, on a larger population in order to generate guidelines to better medical practice on this matter.

Corresponding author: Sorin Viorel Parasca, Lecturer, MD, PhD; e-mail: sorinparasca@yahoo.com; Mihaela-Cezarina Mehedinti, Professor, MD, PhD; e-mail: mihaela_hincu10@yahoo.com

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22. Alveolus soft and bone tissue regeneration after laser biomodulation - a histological study

Diana Florina Nica, Elena Rodica Heredea, Darinca Carmen Marilena Todea

Functional and esthetic recovery of the patient after tooth extraction is a concern in the nowadays-dental medicine. Immediate implant placement in fresh sockets in posterior sides of the jaws is difficult because of the high amount of bone loss and the disparity between the diameter of the alveolus and the implant. The objective is to evaluate the effect of laser biomodulation alveolar socket healing process of healthy patients. A number of 36 molars have been extracted due to advanced caries lesions from the same dental arch but on opposite sites. Laser irradiation was performed on one side after extraction; the other side was used as control. An Epic-X laser diode (Biolase) Indium-Gallium-Arsenide-Phosphorus (In-Ga-As-P) 940 nm was used in a continuous mode, 0.9 W, 36 J for 80 seconds, daily exposure, in the first seven days after extraction. Specimens of soft and hard tissue were surgically incised and removed by a 4.4 mm diameter trepan from the extraction sites, eight weeks after the surgical procedure. The specimens were prepared by use of two staining procedures: Hematoxylin-Eosin (HE) and Mallory s trichrome. The prepared slides were examined under Leica DM750 optical microscope, 5x and 10x magnification. Laser biomodulation therapy accelerates bone formation by increasing osteoblastic activity. The histological study demonstrates early new bone formation, the regeneration effects in fresh intact bony alveolus compared with the soft and bone regeneration level of non-treated fresh alveolus. Laser biomodulation therapy accelerates soft tissue regeneration and bone formation.

Corresponding author: Darinca Carmen Marilena Todea, Professor, DMD, PhD; e-mails: todea.darinca@umft.ro, carmen.todea@gmail.com

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23. The impact of imagistic evaluation of premalignant and malignant lesions of the breast confirmed in histopathological terms

Alina Oana Rusu-Moldovan, Madalina Gabriela Radu, Maria Iuliana Gruia, Dan Nicolae Patroi, Camelia Manuela Mirza, Dan Mihu

Breast cancer is a condition with the highest incidence of all neoplasms and a frequent cause of death. Due to increased incidence and mortality, this disease motivates healthcare professionals to redirect efforts to develop effective strategies for secondary prophylaxis. Imagistic investigations play an important role both in detecting lesions and in post-therapeutic evolutionary follow-up. The objective of the paper is to study cases of premalignant and malignant tumors, with a view to their imagistic identification confirmed in terms of histopathology, to highlight the accuracy of the imagistic examination as an important factor in the diagnosis and adaptation of an appropriate therapeutic attitude. The study was performed on a batch of 768 patients admitted to the Department of Surgery III, Prof. Dr. Alexandru Trestioreanu Institute of Oncology, Bucharest, Romania. The classical examined hypothesis is local examination, mammography, ultrasound, with its variations, and histopathological (HP) confirmation, either by thick-needle biopsy puncture and/or tumor excision. By correlating with HP examination of the imagistic representation of the lesion, we can show the importance or limitation of each imagistic investigation, but especially its usefulness in the choice of therapeutic behavior. Breast cancer screening using classical techniques currently requires implementation of modern techniques to diagnose this disease.

Corresponding author: Dan Nicolae Patroi, Associate Professor, DMD, PhD; e-mail: dan.patroi@gmail.com

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24. Incidence of the middle mesial canals in mandibular permanent molars in a Romanian population by cone-beam computed tomography

Paula Perlea, Anca Nicoleta Temelcea, Cristina Coralia Nistor, Irina Maria Gheorghiu, Alexandru Andrei Iliescu

Introduction: Untreated middle mesial canals (MMCs) of mandibular permanent molars can result in endodontic treatment failure. Aim: The aim of this retrospective study was to investigate the incidence of MMC of mandibular molars in a Romanian population. Patients, Materials and Methods: In total, there were evaluated 144 mandibular first permanent molars and 140 mandibular second permanent molars by using cone-beam computed tomography (CBCT) scans. Results: The MMC was identified in 5.67% of mandibular first permanent molars, respectively in 4.28% of mandibular second permanent molars. The male/female ratio of MMC presence was 1:3 of mandibular first molars and inverted for mandibular second molars (5:1). The presence of MMC in mandibular first molars was associated in all cases of our study with a second distal canal, unlike the mandibular second molars where no second distal canal was associated with a MMC. Conclusions: In Romanian population, the MMC of mandibular first molars, when present, is commonly associated with a second distal canal, unlike the mandibular second molars where the occurrence of a MMC was associated with only one distal canal. When performing the preoperative evaluation, it has also to be considered the patient gender, since the male/female ratio of MMC was 1:3 in mandibular first molars and 5:1 in mandibular second molars.

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

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25. Histochemical, immunohistochemical and ultrastructural analysis of aortic wall in neonatal coarctation

Irena Tanaskovic, Slobodan Ilic, Vladimir Jurisic, Milena Lackovic, Zoran Milosavljevic, Vesna Stankovic, Aleksandra Aleksic, Maja Sazdanovic

The neonatal type of coarctation is characterized by the presence of the ductal sling and coarctational shelf placed proximally in relation to the ductal orifice. Those morphological features are not described in detail yet from immunohistochemical and transmission electron microscopy (TEM) aspects, so the aim of this study was to investigate the smooth muscle cells (SMCs) phenotype in aortic intimal thickening, presence of inflammatory cells and contents of intimal and medial, and adventitial connective tissue. We examined samples of coarctation segments excised at surgery after end-to-end anastomosis from 30 patients, ages from 14 days to three months, histochemicaly, immunocytochemically and by TEM. In all samples, it is noticed focal intimal thickening on the posterior aortic wall, with accumulation of SMCs, which show immunoreactivity on alpha-smooth muscle actin (alpha-SMA) and vimentin (but not on desmin) and also expressed proliferating cell nuclear antigen (PCNA) and S-100 protein. At TEM analysis, those SMCs show a fibroblast-like morphology, so their functions could be to proliferate and secrete extracellular matrix (ECM) components (a synthetic phenotype). In all studied samples of the coarctation, on the posterior wall, the immunocytochemical and TEM examination revealed the presence of SMCs of the synthetic phenotype. Results also showed an increase of the cell number in intima of this part of aortic wall, followed by proliferated SMCs in inner media and absence of inflammatory cells. This finding suggests that proliferation of the SMCs, their synthetic activity and increase of the cell number could lead to formation of the intimal thickening on the posterior wall.

Corresponding author: Vladimir Jurisic, Professor, MD, PhD; e-mail: jurisicvladimir@gmail.com

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26. Familial Mediterranean fever-associated renal amyloidosis: case report and review of the literature

Andreea Gabriella Andronesi, Gener Ismail, Mihaela Gherghiceanu, George Mitroi, Mihai Cristian Harza

Familial Mediterranean fever (FMF) is a hereditary autoinflammatory disease, which is diagnosed especially in Mediterranean patients, but is a rare disorder in our geographical area. Due to its rarity and symptoms consisting mainly in recurrent episodes of fever and serositis, it may be mistaken with other, more frequent diseases, especially acute abdomen and systemic rheumatic diseases. The most important life-threatening complication is secondary amyloidosis, which usually affects kidneys, with proteinuria up to nephrotic syndrome and chronic kidney disease progressing to end-stage renal disease requiring dialysis or transplantation. In patients with suspected amyloidosis, kidney biopsy or submucosal rectal biopsy are the methods of choice for diagnosis. Kidney biopsy is also useful in patients with FMF who start to develop proteinuria, since other non-amyloid glomerular involvement may appear in FMF. Colchicine is now the gold standard for treatment, not only to reduce the frequency of attacks but also to improve renal prognosis. For this reason, the sooner the diagnosis is established the better the prognosis will be since the patient will benefit from the appropriate treatment with Colchicine. We present the case of a young female patient diagnosed through kidney biopsy with amyloid A (AA) amyloidosis after 30 years of evolution of FMF and we review the present knowledge regarding the pathogenesis and management of this rare genetic disease.

Corresponding author: Andreea Gabriella Andronesi, MD, PhD; e-mail: andreea.andronesi@yahoo.com

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27. Type II pleuropulmonary blastoma in a 2-year-old girl: a case report

Teodora Smaranda Arghirescu, Ada Maria Carstea, Licinia Andrada Oprisoni, Elena Rodica Heredea, Ovidiu Nicolae Burlacu, Ioana Delia Horhat, Calin Marius Popoiu

Pleuropulmonary blastoma (PPB) is a very rare, malignant aggressive primary lung tumor, which occurs mainly in children less than 5 years old. Due to its poor prognosis, it is aggressively treated with multimodal therapy including surgery and chemotherapy. We present a case of PPB in a 2-year-old girl who was brought to the pediatric clinic for fever, cough and respiratory distress. Imaging studies showed a heterogeneous solid-cystic mass (12/9/11 cm) in the upper right pulmonary lobe. Through right thoracotomy, a specimen was obtained, the histopathological and immunohistochemical features of the specimen being suggestive for type II PPB. Aggressive chemotherapy and right pneumonectomy resulted in control of disease, the patient being currently in complete remission four years after the diagnosis.

Corresponding author: Teodora Smaranda Arghirescu, Associate Professor, MD, PhD; e-mail: sarghirescu@yahoo.com; Ioana Delia Horhat, MD, PhD; e-mail: deliahorhat@yahoo.com

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28. The crucial role of SRY gene in the determination of human genetic sex: 46,XX disorder of sex development

Cristina-Crenguta Albu, Dinu-Florin Albu, Ana-Roxana Musat, Ioana Georgeta Stancu, Stefan-Dimitrie Albu, Anca Patrascu, Alexandru Marian Goganau

Prenatal diagnosis of disorder of sex development (DSD) is very rare and is estimated to occur in 1/2500 pregnancies. A group of DSDs are the 46,XX testicular DSD. Today, the incidence of 46,XX testicular DSD is estimated at 1/20 000 newborn males. A majority of males with DSD have an unbalanced X;Y exchange involving the pseudoautosomal region, with translocation of the sex-determining region of the Y (SRY) gene onto Xp23.3. We present a rare case of very early prenatal diagnosis and management of a fetus with SRY-positive 46,XX testicular DSD.

Corresponding author: Cristina-Crenguta Albu, Lecturer, MD, PhD; e-mail: crenguta.albu@yahoo.com

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29. Blue nevus-like melanoma of the uterine cervix. Case report and review of the literature

Dan Tudor Eniu, Adelina Staicu, Oana Somcutian, Rares Buiga, Camelia Albu, Iulian Gabriel Goidescu, Angelica Rita Chiorean, Codrut-Cosmin Nistor-Ciurba

We present the clinical and pathological aspects of a patient diagnosed with a very rare tumor, a blue nevus-like melanoma of the uterine cervix. The patient turned to our Service for a second opinion regarding a cervical polyp causing vaginal bleeding, polyp which has been excised in another Hospital and interpreted initially as a pleomorphic sarcoma. In the presentation, we emphasize upon the stages of solving a difficult diagnosis, pathological description and treatment of these rare, aggressive tumors with poor prognosis, which represent the fundamental precondition in order to formulate the best therapeutic strategy.

Corresponding author: Adelina Staicu, MD, PhD; e-mail: adelina.staicu@umfcluj.ro

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30. Hepato-spleno-mesenteric trunk, in association with an accessory left hepatic artery, and common trunk of right and left inferior phrenic arteries, independently arising from left gastric artery: case report using MDCT angiography

Laura-Andreea Bolintineanu, Adina-Nadia Costea, Nicoleta Iacob, Agneta Maria Pusztai, Horia Ples, Petru Matusz

The authors report the case of a 53-year-old male found to have an extremely rare case of a triple anatomical variation highlighted by multidetector computed tomography (MDCT) angiography, with the presence of a hepato-spleno-mesenteric trunk (HSMT) in association with an accessory left hepatic artery (ALHA) and a common trunk origin of right (RIPA) and left (LIPA) inferior phrenic arteries from left gastric artery (LGA) arising independently from the abdominal part of aorta (AA). The HSMT with an endoluminal diameter of 10.9 mm at its origin, and a length of 4 mm arose from the anterior wall of the AA at the level of 1/2 upper part of the L1 vertebral body. From the distal portion of HSMT, give birth to the hepato-splenic trunk (HST) and to the superior mesenteric artery (SMA). HST, with a diameter at origin of 9.2 mm and 22.3 mm long, has an upward trajectory and done with the anterior face of AA an open angle to the top of 69 degrees. From the distal part of the HST, arise common hepatic artery (CHA) and splenic artery (SA). The LGA, with an endoluminal diameter of 4.2 mm at origin, arose directly from the anterior wall of the AA at the level of the lower 1/3 of T12 vertebral body, 8.2 mm above the origin of the HSMT. It ran upwards in front of the AA and after 59.5 mm gave rise to an ALHA. At 18.6 mm from its aortic origin, LGA gives birth to an inferior phrenic artery trunk (IPAT), which has at origin an endoluminal diameter of 2.6 mm and a length of 2.4 mm. The RIPA and LIPA have to origin a diameter of 2.3 mm and 1.7 mm, respectively. Knowledge of this anatomical variation is important for anatomists, interventional radiologists, vascular medicine experts, oncologists, vascular, and hepatic surgeons.

Corresponding author: Agneta Maria Pusztai, Assistant Professor, MD, PhD; e-mails: pusztai.agneta@umft.ro, agipusztai@yahoo.com

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31. Superior vena cava syndrome and pulmonary adenocarcinoma

Vitorino Modesto dos Santos, Sandro Jose Martins, Mariely Fernanda Silva Helbigen, Victor Eduardo de Almeida e Franca, Renata Atahyde de Casasanta, Eslei Judson Lisboa Leitao

We report a large-cell adenocarcinoma of the lung in a tobacco smoker with classical superior vena cava syndrome and digital clubbing. Computed tomography and nuclear magnetic resonance revealed the involvement of the vena cava and metastases in the left adrenal gland and central nervous system. Biopsy samples of the mass yielded the diagnosis. The patient underwent a schedule of palliative chemotherapy and brain radiotherapy.

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

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32. Frostbite arthropathy - a rare case of osteoarthritis, review of the literature and case presentation

Laszlo Irsay, Rodica Ana Ungur, Ileana Monica Borda, Alina Deniza Ciubean, Iulia Moldovan, Magdalena Rodica Traistaru, Kamal Constantin Kamal, Diana Kamal, Viorela Mihaela Ciortea

Frostbite affects more commonly the northern population then it was suspected earlier, but wherever cold winter occurs, cold caused lesions are reported. Most often, it is described as soft tissue lesions, but deeper structures like tendons, ligaments, muscles, cartilage or bones can be affected. All extremities can be involved; lesions can lead to necrosis and amputations. First documented cases were described during military actions, but occupational or recreational activities can also be a risk factor for frostbite. Frozen or frostbite arthropathy is a rare cause of osteoarthritis. Usually, arthritis appears after a long time after frostbite, it can be decades apart. Frostbite arthropathy can result in different debilitating conditions. The current review describes the most important changes in frostbite and a rare but very serious late complication, which lead to arthropathy.

Corresponding author: Alina Deniza Ciubean, Assistant Lecturer, MD, PhD Student; e-mail: alina_med87@yahoo.com

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33. Nodular subcutaneous lesion - an alarming sign for an upcoming pancreatic disorder

Irina Tica, Costin Niculescu, Liliana Mocanu, Madalina Gabriela Iliescu, Vlad-Iustin Tica, Zizi Niculescu

Pancreatic panniculitis represents a rare dermatological manifestation mainly due to a pancreatic disorder, but other etiologies are possible. Even rarer, it can occur prior to the clinical signs of the underlying disease, and its presence must orientate the investigations especially towards pancreas, liver and neuroendocrine system. We report a rare case of a 47-year-old male patient who presented to the Emergency Unit complaining about a two weeks-long-persistent pain in the upper abdomen and biliary vomiting. The medical history included alcohol abuse. Several days prior to the onset of these symptoms, the patient has noticed the occurrence of a nodular inflammatory lesion of 5/3 cm on the right calf (this makes the case even rarer). Based on clinical aspect and high levels of pancreatic enzymes, acute pancreatitis was diagnosed. Contrast-enhanced abdominal computed tomography (CT) revealed a cystic pancreatic mass and dilated intrahepatic biliary ducts. Abdominal magnetic resonance imaging (MRI) revealed a cystic tumor of the pancreatic head and thrombosis of the portal vein, which increased the suspicion of pancreatic adenocarcinoma. Biopsy was performed from the calf nodular lesion, with the diagnosis of panniculitis. This case, besides its rarity, supports the clinical important value of a pancreatic workup in case of histologically proved panniculitis, even without pancreatic related symptoms.

Corresponding author: Vlad-Iustin Tica, Professor, MD, PhD; e-mail: vtica@eeirh.org

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34. Common hepatic artery arising from the left gastric artery: a case report using MDCT angiography and a brief review of the literature

Adina-Nadia Costea, Nicoleta Iacob, Agneta Maria Pusztai, Horia Ples, Petru Matusz

We report a very rare case of a 67-year-old male with the presence of a common hepatic artery (CHA) arising from the left gastric artery (LGA) in association with a presence of a gastro-splenic trunk (GST), found incidentally on multidetector computed tomography (MDCT) angiography, used to investigate peripheral vascular disease. The GST arises from the anterior aspect of the abdominal aorta (AA), at the level of lower 1/3 of L1 vertebral body. The GST has a slightly concave trajectory to the right, and ends dividing into splenic artery (SA) and LGA. In the initial part of its trajectory, the SA it is wedged at 180 degrees, pointing to the left, to the splenic hilum. The LGA has two different portions: the first dilated, initially oriented towards the higher, and then aligns to the infero-lateral left and gives birth to the second portion; the narrow portion, oriented initially horizontally, and then lower to the right. Dilated portion of LGA is continued with CHA. The CHA trunk is cuddling in a horizontal plane, at 180 degrees, and is then oriented towards the fissure of the ligamentum venosum for entering in the liver parenchyma. At 51.7 mm from the origin, the CHA gives rise to the left hepatic artery (LHA), and after another 58 mm to the right hepatic artery (RHA), and finally continues with the gastroduodenal artery (GDA). Knowledge of this anatomical variation should be considered in planning and performing vascular surgery in the supramesocolic floor of the abdominal cavity.

Corresponding author: Agneta Maria Pusztai, Assistant Professor, MD, PhD; e-mails: pusztai.agneta@umft.ro, agipusztai@yahoo.com

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35. Non-syndromic familial hypodontia: rare case reports and literature review

Ruxandra Margarit, Oana-Cella Andrei, Livia-Alice Tanasescu, Catalina Farcasiu, Adriana Bisoc, Magdalena-Natalia Dina, Mihai Burlibasa, Dana-Cristina Bodnar

Congenital absence of the teeth, affecting both physiognomy and mastication, can have a great impact on patients quality of life. It may appear unilateral or bilateral; frequently, it associates with certain general conditions. Familial hypodontia in clinically healthy patients is rare. Genetic transmission, as a determinant factor in missing teeth, can be autosomal dominant, recessive, or related to the sex chromosomes. In case of congenitally missing permanent teeth, the corresponding deciduous teeth can be still found on the arch at adult age. The aim of this article is to present rare cases of familial non-syndromic unilateral and bilateral hypodontia in Romanian adult siblings, highlighting also a cross gene transmission between aunt and niece and evaluating the treatment options in accordance with patient s age and oral status. It shows that early diagnosis of hypodontia is crucial for the patient s future oral health. The decision to keep the temporary teeth or to extract them is influenced by the presence and status of the deciduous teeth, patient s access to treatment and parent s agreement. Asymptomatic adult patients, in which hypodontia was diagnosed during a routine control, do not usually solicit therapeutic intervention until the deciduous teeth are also lost; still, in situations where complications arise through their loss, the treatment of hypodontia is complex, involving a close collaboration between a team of specialists. The article also includes a detailed review of literature referring to the prevalence of hypodontia among different populations.

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

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36. Abnormal entrance of the umbilical vein into the liver and fetal thrombotic vasculopathy in a fetus: a rare combined case

Soultana Meditskou, Alexandra Grekou, Maria Eleni Manthou, Bassam Razcha, Christos Arnaoutoglou, Konstantinos Natsis

The left umbilical vein is lodged on the fissure of the round ligament of the liver, from umbilicus to portal vein, just on the inferior margin of the falciform ligament. We report an anomalous course of the umbilical vein in a 39-week-old deceased male fetus, also exhibiting fetal thrombotic vasculopathy (FTV). In the present case, the umbilical vein entered the liver through a tunnel on its anterior part of the diaphragmatic surface, close to the lower free edge of the liver and next to the falciform ligament. The entrance of the tunnel was covered by Glisson s capsule. The round ligament s fissure was absent. The quadrate lobe was not well demarcated and the visceral surface of the liver had an abnormal appearance. The coexistence of FTV was confirmed histologically. The possibility of a tunnel present for the umbilical vein, instead of a fissure, is of great significance for surgical approaches or for radiological evaluations, even though it is not likely to cause intrauterine fetal death. However, the anomalous course of umbilical vein might be a predisposing factor for FTV, which often leads to intrauterine fetal death.

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

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37. A rare case of synchronous ovarian tumors: clinical case report and literature review

George-Alexandru Rosu, Gheorghe Otto Furau, Cringu Antoniu Ionescu, Mihai Cornel Traian Dimitriu, Adrian Neacsu, Raluca Gabriela Ioan, Florin Daniel Calin, Alexandra Matei, Mihail Banacu, Ina Popescu, Diana Gheorghiu, Ilinca Neacsu, Nicolae Bacalbasa, Cristian George Furau

Epithelial ovarian carcinoma makes up 90-95% of all ovarian malignancies, taking into account also low-malignant-potential tumors. The Krukenberg tumor is a rare metastatic adenocarcinoma (ADK) in the ovary, representing 1-2% of ovarian tumors. Multiple primary malignant neoplasms may exist when more than one cancerous tumor is diagnosed in the same or a different organ. The incidence of multiple primary cancers among malignancies is between 2.4% to 8%. The aim of this paper is to report the case of a 47-year-old patient with two synchronous malignant tumors involving both ovaries, one diagnosed as primary papillary serous cystadenocarcinoma and the other one diagnosed as ovarian metastasis (Krukenberg tumor) of a synchronous colorectal ADK, and the complex diagnostic and therapeutic challenges that such a rare case poses. Histopathological (HP) examination and especially the immunohistochemical analysis had a determining role in differentiating between an ovarian primary tumor and a metastasis from a gastrointestinal tract cancer. The tumors examination for somatic mutations of Kirsten rat sarcoma viral oncogene homolog (KRAS) and neuroblastoma RAS viral oncogene homolog (NRAS) genes was performed in order to individualize the chemotherapic treatment in this difficult case. The conclusion of this case is that, although synchronous multiple primary cancers in a young patient are a rare condition, this situation should be taken into account in the differential diagnosis when we encounter clinical and HP diagnostic challenges.

Corresponding author: Gheorghe Otto Furau, Associate Professor, MD, PhD; e-mail: gfurau@yahoo.com

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38. Metastatic renal cell carcinoma to the earlobe 27 years after nephrectomy

Theodoros Tzigkalidis, Kalliopi Patsiaoura, Efthimios Giannoulis, Konstantinos Sapalidis, Dimitrios Papanikolaou, Soultana Meditskou

We present a case of a nodule on the earlobe of an elderly patient, without any known clinical history. Microscopic examination revealed a tumor with morphology reminiscent of metastatic clear cell renal cell carcinoma. The results of an extensive immunohistochemical (IHC) examination confirmed our initial diagnosis and further investigation of the patient s medical history revealed that a unilateral nephrectomy had been performed 27 years prior to the current tumor. We are reporting this case to emphasize the long interval between the primary tumor and its metastasis in an extremely unusual site, with a brief discussion on the ability of this particular neoplasm for extremely late metastasis to any site on the human body. Also, we are highlighting the extensive step-by-step IHC examination to confirm the diagnosis in routine pathology.

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

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39. Differential diagnosis difficulties related to infantile hemangioma - case report and literature review

Elena Tarca, Elena Cojocaru, Solange Tamara Rosu, Lacramioara Ionela Butnariu, Petru Plamadeala, Stefana Maria Moisa

Infantile hemangioma is a benign vascular tumor that is often present in the cephalic region and can grow rapidly in size, causing serious complications. The hemangioma with oro-maxillofacial sphere localization may often pose differential diagnosis problems, requiring additional investigations. We present the case of a 3-month-old baby who was brought to the Emergency Room for acute respiratory failure and dysphagia caused by the rapid increase in size of a soft palate and lateral pharyngeal wall tumor. The clinical examination revealed a wine stain hemangioma in the inter-eyebrow and frontal areas, a hemangioma in the right genial area, 1/1.5 cm in diameter, growing rather in depth than on the surface, and a purplish-blue tumoral mass with irregular edges, grown in the soft palate and in the right lateral wall of the pharynx, which impaired both eating and breathing. Obstructive phenomena have been aggravated by an acute respiratory infection. Due to the inconsistencies between different medical specialties about the nature of the tumor and the suspicion of malignancy, in order to establish the correct diagnosis and therapeutic management, urgent tumor biopsy was required. After starting oral treatment with Propranolol, the evolution was favorable. Infantile hemangiomas may sometimes be hard to diagnose, requiring additional imaging examinations, and sometimes-pathological examination. Since it may affect a vital function, or the patient s esthetic appearance, or if the tumor has ulcerated, bleeds or got infected, the certain diagnosis and the onset of treatment should be done as soon as possible.

Corresponding author: Elena Cojocaru, Lecturer, MD, PhD; e-mail: elatarca@gmail.com

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40. Rudolf Virchow, the founder of cellular pathology

Domenico Ribatti

The cell theory was firstly formulated by Schleiden, Schwann, and Virchow. They sustained that the cells originate from pre-existing cells and that the living organisms are composed by cells organized in different tissues. In particular, Virchow not only established the principle of omnis cellula e cellula, but considered for the first time that alterations on cell organization was at the basis of disease.

Corresponding author: Domenico Ribatti, Professor, MD, PhD; e-mail: domenico.ribatti@uniba.it

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41. The mysterious mental illness of a philosopher: the case of Blaise Pascal

Anca Sava, Marius Dumitrescu, Gabriela Florenta Dumitrescu, Mihaela Dana Turliuc, Manuela Ciocoiu, Viorel Scripcariu

Blaise Pascal (1623-1662) was a French philosopher, who wrote the Pensees, a collection of thoughts about the apparent insignificance of human existence. In the last three centuries, it was claimed that his disease was mental. Hysteria, melancholia, and post-traumatic neurosis were taken into consideration, but none of the proposed diagnoses seems to be satisfactory. The aim of our work is to identify Pascal s mysterious illness. We correlated the symptoms of the indirect anamnesis (Pascal s letters to friends, letters and biographies made by his sisters and granddaughter) and autopsy data. Based on these data, we consider that Pascal s illness, which has affected him all his life and caused his death, was celiac disease, the diagnosis being supported by: childhood abdominal pain with gradual progression to neurological manifestations in his middle-age, which were expressed by migraine-type headaches, peripheral neuropathy, epilepsy, neuropsychiatric disorders (depression). The hypothesis of a celiac disease is also argued by autopsy data: lack of closure of the fontanelle due to type D hypovitaminosis, intestinal gangrene because celiac disease accelerates the post-mortem autolysis, gliosis and calcification of the nervous tissue. The second cause of his death was a chronic traumatic subdural hematoma, probably located in the superior temporal region, which was the reason for his left-sided hemianopsia that occurred immediately after a carriage accident. Conclusions: Pascal s philosophy reflects his own inner life, which was deeply influenced by the organic affections he suffered.

Corresponding author: Marius Dumitrescu, Professor, PhD; e-mail: dumitrescu.marius66@yahoo.com; Mihaela Dana Turliuc, Associate Professor, MD, PhD; e-mail: turliuc_dana@yahoo.com

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42. Leonardo da Vinci - ingenious anatomist: 500 years since the death of the famous erudite

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

Born on April 15, 1452, in a modest family in a hamlet from Tuscany, Leonardo da Vinci became the unassailable icon of Renaissance. Pushed throughout his entire life by his relentless curiosity, he was a painter, draughtsman, sculptor, poet, musician, writer, engineer, stage designer, architect, physicist, astronomer, cartographer and anatomist. His earliest surviving anatomical drawings (ca. 1485-1493) include studies of the skull, meninges, brain and cerebral ventricles. He was the first to pith a frog, concluding that piercing the spinal medulla will result in immediate death - a completely unexpected result in that era. In an effort to better understand the origins of the sensory and motor functions of the brain - which at the time was believed to be in the ventricles - he developed a method of injecting hot wax into the ventricles of an ox. He was the first to correctly describe the four ventricles of the brain. Thus, he circumvented a 16 century-long flaw in the dissection technique, which did not allow the correct study of the shape of the ventricles - decapitation and drainage of fluids before study. Even though he was never formally educated in the study of medicine, his work continues to inspire us today, 500 years after his death.

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

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