Search

Purpose This study aims to explore the extent and types of E-Learning used, as method and tool, to support education for sustainable development (ESD); and to understand the coverage of Sustainable Development Goals (SDGs) in massive open online courses (MOOCs). Design/methodology/approach The study extends the morphological box of ESD in higher education by nonformal and informal education, exploring the types of blended and online learning and adding the SDGs as a new criterion. The study subjects are Nordic UN Principles for Responsible Management Education (PRME) members. Through content analysis and thematic coding of reports by higher education institutions (HEIs), different E-Learning methods are identified; furthermore, 30 MOOCs are analyzed. Findings HEIs apply a variety of blended and online learning to advance ESD for formal and nonformal education. The MOOCs offered by Nordic HEIs predominantly cover four SDGs (9: Industry, Innovation and Infrastructure; 13: Climate Action; 11: Sustainable Cities and Communities; and 16: Peace, Justice and strong Institutions), but there is nothing on SDG 2: No Hunger. That is in line with the Nordic countries’ status as developed economies, where these topics are often framed as political and societal priorities. Practical implications The study’s results suggest that to avoid overlaps and fill gaps in ESD, the offer of open online courses should be orchestrated. Furthermore, HEIs can use our method to analyze their E-Learning courses related to SDGs. Originality/value This study shows how business schools, especially Nordic UN PRME members, contribute to the SDGs by their MOOC coverage.

The present research is focused on three different classes of orthodontic cements: resin composites (e.g., BracePaste); resin-modified glass ionomer RMGIC (e.g., Fuji Ortho) and resin cement (e.g., Transbond). Their mechanical properties such as compressive strength, diametral tensile strength and flexural strength were correlated with the samples’ microstructures, liquid absorption, and solubility in liquid. The results show that the best compressive (100 MPa) and flexural strength (75 Mpa) was obtained by BracePaste and the best diametral tensile strength was obtained by Transbond (230 MPa). The lowestvalues were obtained by Fuji Ortho RMGIC. The elastic modulus is relatively high around 14 GPa for BracePaste, and Fuji Ortho and Transbond have only 7 GPa. The samples were also subjected to artificial saliva and tested in different acidic environments such as Coca-Cola and Red Bull. Their absorption and solubility were investigated at different times ranging from 1 day to 21 days. Fuji Ortho presents the highest liquid absorption followed by Transbond, the artificial saliva has the best absorption and Red Bull has the lowest absorption. The best resistance to the liquids was obtained by BracePaste in all environments. Coca-Cola presents values four times greater than the ones observed for artificial saliva. Solubility tests show that BracePaste is more soluble in artificial saliva, and Fuji Ortho and Transbond are more soluble in Red Bull and Coca-Cola. Scanning electron microscopy (SEM) images evidenced a compact structure for BracePaste in all environments sustaining the lower liquid absorption values. Fuji Ortho and Transbond present a fissure network allowing the liquid to carry out in-depth penetration of materials. SEM observations are in good agreement with the atomic force microscopy (AFM) results. The surface roughness decreases with the acidity increasing for BracePaste meanwhile it increases with the acidity for Fuji Ortho and Transbond. In conclusion: BracePaste is recommended for long-term orthodontic treatment for patients who regularly consume acidic beverages, Fuji Ortho is recommended for short-term orthodontic treatment for patients who regularly consume acidic beverages and Transbond is recommended for orthodontic treatment over an average time period for patients who do not regularly consume acidic beverages.

Introduction. Hypereosinophilia (HE) is defined as an absolute eosinophil count >1.5 x 109/L in the peripheral blood on two examinations separated in time by at least one month and/or pathologic confirmation of tissue HE. A hypereosinophilic syndrome (HES) is defined by the association of HE with eosinophil-mediated organ damage and/or dysfunction if other potential causes of them have been excluded. Case report. We report a case of a 52-year-old woman admitted to Rheumatology Department for diffuse, highly intense (10/10) myalgia, associated with paravertebral, upper and lower limbs muscular edema and stiffness, having the onset of symptoms for about 4 months. During rheumatological evaluation, the patient developed posterior cervical diffuse pain with brachial irradiation associated with severe functional impotence reason for which it was indicated MRI of cervical spine. The blood count showed leucocytosis with hypereosinophilia. No evidence of Raynaud’s phenomenon, cutaneous and muscular sclerosis or visceral involvement. All muscular groups and deep fascia appeared affected on the whole-body MRI and the findings were suggestive for Shulman’s eosinophilic fasciitis or eosinophilic myopahty. All autoimmune, parasitic and allergic causes for myopathy were ruled out. Muscle tissue biopsy revealed high eosinophilic infiltrate predominantly in the deep muscular fascia, in the striated muscles and in the superficial dermis. The patient received methyl-prednisolone pulse-therapy with a low-maintenance dose of prednisone which showed clinical improvement and normalized peripheral blood eosinophilia. A hematologic evaluation revealed high percentage of bone marrow eosinophil count which harbored FIP1L1-PDGFR alpha mutation and data was suggestive for the diagnosis of myeloproliferative variant of HES syndrome along with Shulman’s eosinophilic fasciitis for which Imatinib treatment was indicated. Conclusion. The particularity of this case consists in the diagnosis of a myeloproliferative variant of HES with atypical presentation as a Shulman’s eosinophilic fasciitis, a rheumatological condition. Even though initial symptoms were suggestive for a myopathy, it was difficult to establish the positive diagnosis without any obvious paraclinical data. Further investigations such as MRI and muscle biopsy were conclusive for the diagnosis of Shulman’s eosinophilic fasciitis and clinical improvement was observed after corticosteroid treatment. Considering that after 4 months of evolution of the disease the patient did not present any atrophic lesions of the affected muscles and skin characteristic for Shulman’s eosinophilic fasciitis the patient was referred to Hematology Department with the diagnosis of HES. Advanced exams established the hematological condition as primary FIP1L1-PDGFR positive HES which could benefit from tyrosine-kinase inhibitors treatment (Imatinib) known to induce in this situation improved clinical and paraclinical status.

Brackets are metallic dental devices that are very often associated with acidic soft drinks such as cola and energy drinks. Acid erosion may affect the bonding between brackets and the enamel surface. The purpose of this study was to investigate the characteristics of brackets’ adhesion, in the presence of two different commercially available drinks. Sixty human teeth were divided into six groups and bonded with either resin-modified glass ionomer (RMGIC) or resin composite (CR). A shared bond test (SBS) was evaluated by comparing two control groups with four other categories, in which teeth were immersed in either Coca-ColaTM or Red BullTM energy drink. The debonding between the bracket and enamel was evaluated by SEM. The morphological aspect correlated with SBS results showed the best results for the samples exposed to artificial saliva. The best adhesion resistance to the acid erosion environment was observed in the group of teeth immersed in Red BullTM and with brackets bonded with RMGIC. The debonded structures were also exposed to Coca-ColaTM and Red BullTM to assess, by atomic force microscopy investigation (AFM), the erosive effect on the enamel surface after debonding and after polishing restoration. The results showed a significant increase in surface roughness due to acid erosion. Polishing restoration of the enamel surface significantly reduced the surface roughness that resulted after debonding, and inhibited acid erosion. The roughness values obtained from polished samples after exposure to Coca-ColaTM and Red BullTM were significantly lower in that case than for the debonded structures. Statistical results evaluating roughness showed that Red BullTM has a more erosive effect than Coca-Cola™. This result is supported by the large contact surface that resulted after debonding. In conclusion, the prolonged exposure of the brackets to acidic drinks affected the bonding strength due to erosion propagation into both the enamel–adhesive interface and the bonding layer. The best resistance to acid erosion was obtained by RMGIC.

Introduction: We present our 6-year experience with liver surgery and ablative techniques. Method: An observational retrospective analysis from a prospectively maintained database was performed in our department. All the patients with liver resection, liver resection combined with intraoperative ablative techniques and percutaneous ablative techniques were included from January 1st 2014 to December 31st 2020. Results: There were 249 patients analyzed: 273 patients with liver resection, 12 patients with liver resection combined with intraoperative MWA, 9 patients with open surgery MWA, 12 patients with percutaneous MWA, 1 patient with TACE and MWA, 1 patient with TACE and PEI, 10 patients with TACE, and 2 patients with PEI. Conclusion: Liver disease should be managed in specialized centers which can offer a wide range of therapeutic options. With the improvement of the surgical technique and perioperative care, including optimized postoperative complication management, and carried out by well-trained surgeons, liver surgery can be performed with low mortality and acceptable morbidity.

Cardiovascular risk assessment in patients with rheumatoid arthritis (RA) is challenging. Not all risk calculators adjust for RA status, yielding discording results. A 56-year-old woman with RA presented for bilateral pain and swelling in the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. She was diagnosed with RA 10 years ago, currently treated with methotrexate (MTX), sulfasalazine, and hydroxychloroquine. She has a history of type 2 diabetes mellitus, a total abdominal hysterectomy with bilateral salpingo-oophorectomy for an epidermoid carcinoma of the cervix, and surgical excision of a pulmonary rheumatoid nodule. Multiple subcutaneous nodules are seen bilaterally on the MCP and PIP joints. MTX may be associated with nodulosis in RA patients, which in turn is related to a further increase in cardiovascular risk compared to RA alone. MTX was discontinued. Abatacept was the biologic of choice, due to recent evidence suggesting superior efficacy in decreasing cardiovascular risk compared to anti-TNF therapies, especially in patients with diabetes and with positive rheumatoid factor. Initiating high-dose statin and abatacept may be a useful primary prevention strategy in complex RA patients that require biologic therapy..

The aim of this research is to investigate penetration of Bromelain into sinonasal mucosa in patients with chronic rhinosinusitis (CRS) versus a control group. Bromelain is derived from pineapple (Ananas comosus) and has various pharmacological effects. 40 patients (20 patients and 20 controls) were enrolled in the study. Bromelain 500 mg tablet twice daily was administered for 30 days. We scored bromelain presence in turbinate and ethmoid mucosas and in the serum of both the groups. Bromelain has an excellent distribution from blood to rhinosinusal mucosa. Its diffusion ability may allow the use of bromelain as an anti-inflammatory agent in paranasal sinus pathologies.Farmacocinetica della Bromelina nel sangue e nella mucosa rinosinusale nei pazienti con rinosinusite cronica.Lo scopo di questa ricerca è quello di accertare la farmacocinetica di Bromelina nella mucosa rinosinusale e nel sangue in pazienti con rinosinusite cronica (CRS) ed in un gruppo di controllo. La Bromelina è un derivato dell’ananas (Ananas comosus) e dispone di vari effetti farmacologici. In questo studio sono stati arruolati 40 pazienti (20 pazienti e 20 controlli). Abbiamo somministrato Bromelina 500 mg in compresse due volte al giorno per 30 giorni. Abbiamo valutato la presenza di Bromelina nella mucosa dei turbinati e dell’etmoide e nel siero. La Bromelina risulta avere un’ottima distribuzione dal sangue alle mucose rinosinusali. In conclusione la capacità di diffusione può permettere l’uso di bromelina come farmaco anti-infiammatorio nelle patologie rinosinusali.

Background. Neuroendocrine tumors of the larynx represent a rare group of neoplasms characterized by pathological and biological heterogeneity. The histological and immunohistochemical diagnosis is the most important step in the appropriate management of these tumors and the prognosis varies according to histological types. Conventional anatomical and functional imaging can be complementary for diagnosis, staging and monitoring of treatment response. Material and methods. Here we report on a case of a laryngeal neuroendocrine small cell carcinoma occurring in a 67-year-old man who was referred to our clinic for clinical reevaluation, diagnosis and treatment. The clinical presentation, the histopathological and immunohistochemical examination and management of this kind of tumor are highlighted. Conclusion. Small cell neuroendocrine carcinomas are very aggressive neoplasms. Patients could benefit from surgery, but radiotherapy and chemotherapy remain the treatment of choice. Very low incidence of neuroendocrine tumors in the larynx and specifically very poor prognosis of neuroendocrine small cell carcinoma encouraged an extensive literature review.

Introduction: The predilection of lobular invasive breast cancer metastasis for the stomach is a topic that has succumbed to various assumptions over the time. Background and Aims: Gastric metastasis of lobular breast cancer is unusual and it can be diagnosed after a long period of time from primary tumor diagnosis. The aim of this study was to review current knowledge regarding the current methods of diagnosis and treatment of gastric metastasis of breast cancer. Methods: A systematic literature search was performed in the Pub-Med Medline database using the terms "gastric metastasis of lobular breast cancer" and "gastric metastasis features" to identify articles relevant to gastric metastasis of lobular breast cancer. Results: Several papers have shown that the topic is rarely presented in the form of case presentations or miniseries by summing up sporadic cases. Due to its rarity and metastasis specificity as host type and appearance after latency of lobular breast cancer makes its gastric metastasis considered atypical and occasionally confused with a primary stomach malignancy. The most recent articles present the immunohistochemical diagnostic criteria of this clinical entity and a new therapeutic approach. Conclusion: At patients with gastric metastasis of lobular breast cancer, obtaining pathologic material and biopsies interpretation can be a real challenge for getting a correct pathologic diagnosis, immunohistochemistry gives us definite diagnosis. The introduction of an endoscopic surveillance protocol for patients with lobular breast cancer could be a proposal for the detection of early gastric metastases allowing for appropriate therapy.

Tumor necrosis factor inhibitors are the first biological agents used in the treatment of rheumatoid arthritis (RA) to have yielded satisfactory results in terms of clinical improvement and radiologic progression, but they are also associated with the possibility of occurrence of a number of autoimmune systemic events [drug-induced lupus (DIL), vasculitis, sarcoidosis] and localized adverse events [uveitis, psoriasis, interstitial lung disease, erythema multiforme including the major form Stevens-Johnson syndrome (SJS)]. During treatment with TNF inhibitors, many patients develop positivity for antinuclear, antihistone and anti-double stranded DNA antibodies, though only a minority of patients will develop clinical manifestations and approximately less than 1% will fulfill the classification criteria for systemic lupus erythematosus. Mucocutaneous manifestations are the most frequent manifestations of DIL following treatment with TNF inhibitors, and can be severe and occasionally difficult to differentiate from erythema multiforme/SJS. Stopping the causative drug (the TNF inhibitor) and general supportive measures are usually sufficient in mild forms, but in moderate to severe forms, systemic glucocorticoids and sometimes immunosuppressive drugs are required. The present report presents the case of a patient with rheumatoid arthritis who developed severe recurrent cutaneous reactions and positive autoantibodies during TNF inhibitor treatment, with difficulties in differential diagnosis and treatment. A review of the literature is also presented.

BACKGROUND. Innate immunity represents the first way of protection against different pathogenic agents. Recently, it has been a permanent interest regarding an innate immune molecule, that is known as palate, lung, nasal epithelial clone (PLUNC). PLUNC is a specific result found in the airways, of approximately 25 kDa, whose encoding is realized by adjacent genes located within a region of 300 kb in chromosome 20; these proteins must be detected predominantly in the superior respiratory tract. MATERIAL AND METHODS. We performed a prospective clinical study on 34 patients with chronic rhinosinusitis and 10 controls, in order to investigate the expression of this protein in nasal tissue of patients affected by chronic rhinosinusitis. We tested the correlation between the existence of this disease and PLUNC proteins positivity. RESULTS. 100% of controls have a+++ rated PLUNC proteins positivity, while cases have a lower percentage of positivity. There were no differences statistically significant between patients with CRSwNP and those with CRSsNP. CONCLUSION. As a response to different irritating agents (bacteria, viruses, chemical factors), nasal mucosa will react by producing PLUNC proteins. PLUNC proteins have a defensive role in the upper airways mucosa.

International audience; Intracranial aneurysms (IAs) are acquired cerebrovascular abnormalities characterized by localized dilation and wall thinning in intracranial arteries, possibly leading to subarachnoid hemorrhage and severe outcome in case of rupture. Here, we identified one rare nonsense variant (c.1378A>T) in the last exon of ANGPTL6 (Angiopoietin-Like 6)—which encodes a circulating pro-angiogenic factor mainly secreted from the liver—shared by the four tested affected members of a large pedigree with multiple IA-affected case subjects. We showed a 50% reduction of ANGPTL6 serum concentration in individuals heterozygous for the c.1378A>T allele (p.Lys460Ter) compared to relatives homozygous for the normal allele, probably due to the non-secretion of the truncated protein produced by the c.1378A>T transcripts. Sequencing ANGPTL6 in a series of 94 additional index case subjects with familial IA identified three other rare coding variants in five case subjects. Overall, we detected a significant enrichment (p = 0.023) in rare coding variants within this gene among the 95 index case subjects with familial IA, compared to a reference population of 404 individuals with French ancestry. Among the 6 recruited families, 12 out of 13 (92%) individuals carrying IA also carry such variants in ANGPTL6, versus 15 out of 41 (37%) unaffected ones. We observed a higher rate of individuals with a history of high blood pressure among affected versus healthy individuals carrying ANGPTL6 variants, suggesting that ANGPTL6 could trigger cerebrovascular lesions when combined with other risk factors such as hypertension. Altogether, our results indicate that rare coding variants in ANGPTL6 are causally related to familial forms of IA.

When interacting with people from different cultures, it is natural to interpret their actions through your own culture's standards. However, doing so can cause misunderstandings. If you employ or conduct business with people from other countries, you can avoid misunderstandings by recognizing cultural differences, such as communication styles, religious beliefs, power structures, and attitudes toward time and work. Your relationships with people from other cultures are enhanced when you are aware of cultural differences.

The purpose of this paper is to present the advantages and disadvantages of neoadjuvant RCT in multimodal therapyof ESC.Between 1998-2014 221 patients were treated with ESC, 85 of whom received neoadjuvant RCT. For these we have made imaging and pathologic assessment of response using RECIST and MANDARD criteria and statistical data were interpreted in terms of the factors that influence the response. Also, they were evaluated statistical correlations between RCT and resectability, postoperative morbidity, mortality and long-term survival.45 patients were imagistic responders and 34 underwent surgery, 40 non-responders of which 14 underwent surgery. Of the 48 surgical patients with preoperative RCT, histopathological evaluation showed that 32 were pathological responders and 16 non responders. There were performed statistical analyzes of correlations between RCT and resectability, stage, location of ESC, morbidity, mortality and survival.RCT increase resectability, improves survival and maximum duration of survival, more in responders than in nonresponders and does not affect postoperative complications and postoperative mortality, nor among the responders or nonresponders. Imaging evaluation result of the response to RCT overestimate responders.

Background: The tyrosine kinase inhibitor, a new treatment option in hepatic carcinoma, may associate thyroid dysfunction like spontaneously remitting thyrotoxicosis followed by hypothyroidism. Case report: A 66-year Caucasian female was first diagnosed and operated for a moderately differentiated rectal adenocarcinoma of 5 centimeters. Immunohistochemistry showed positive VEGF receptor 2 (Flk-1, KDR), VEGF receptor 1(Flt-1), and a Ki67 of 30%. 4 years later a hepatic adenocarcinoma (clear cells variant) was diagnosed. After surgery, daily 400 mg of sorafenib was introduced. Three months later mild symptomatic thyrotoxicosis was seen: palpitations, fatigue, and mild bilateral pedal clonus. Thyroid-stimulating hormone (TSH) was suppressed (0.044 μIU/mL, normal levels between 0.4 and 4.5 μIU/mL), and free levothyroxine (fT4) elevated. The TSH receptor antibody, the antithyreoglobulin and antithyreoperoxidase antibodies were negative. Thyroid ultrasound pointed hypoechogenic, inhomogeneous aspects. She received beta-blocker and within two months thyrotoxicosis remitted but TSH progressively increased suggesting hypothyroidism with level less 5 μIU/mL so no replacement levothyroxine therapy was added yet. Discussions: The exact mechanism of the tyrosine kinase inhibitors-related thyroid malfunction is not fully understood. Non-autoimmune destructive thyroiditis of unknown trigger causes thyrotoxicosis and later hypothyroidism as seen in our case. The clinical features vary from one person to another. The hormone replacement is rarely necessary. The baseline cancer seems irrelevant for thyroid toxicity. In our unusual case the patient had a history of two metachronous cancers. The thyroid follow up is essential during each patient therapy yet a specific pattern of follow-up is not precisely designed. Conclusion: The tyrosine kinase inhibitor-induced thyroid dysfunction includes both thyrotoxicosis and hypothyroidism. We emphasize the idea of periodic endocrine evaluation in oncologic patient treated with this class of drugs.

Background: Gastrointestinal Stromal Tumors (GIST) are rare neoplasms, with sever prognosis in advanced cases. Until the discovery of Tyrosin Kinase Inhibitors (TKI), the life expectancy was very poor for patient with metastatic tumors, postoperative relapses or unresectable disease. Introduction of TKI therapy provided an unexpected survival rate, controlling the disease with very good tolerance. Method: We present a case report representative for GIST pathology. It is the first case of our GIST series of patients, operated in General and Esophageal Surgery Clinic of “St. Mary” Hospital Bucharest. A multidisciplinary approach and a complex, multimodal, surgical and oncological treatment was applied, with good response confirmed by the long-term follow-up. A 79 years old patient was diagnosed in 2004 (at the age of 70 years) with giant gastric GIST. He underwent a total gastrectomy, splenectomy and left pancreatectomy; the resection was considered as R1 because the tumor capsule was not complete. The adjuvant treatment with TKI was started postoperatively for 2 years. The recurrence was noted one year after the adjuvant therapy stop. Then the TKI treatment was restarted with very good tolerance and control of disease at 9 years. Conclusion: The TKI therapy allows long-term control of the malignant GISTs in term of overall survival and quality of life, even when the surgical procedure is not optimal.

In patients with high-stage colorectal carcinomas (CRC), anti-EGFR therapy is known to be effective only in cases with a wild-type K-ras gene status. Different procedures have been proposed for such evaluation.The mutation status of K-ras gene, codons 12, 13 and 61 was determined in 250 CRC cases using the pyrosequencing assay. In addition, we compared the performance of the pyrosequencing procedure with that of PCR-RFLP in a subset (n=100) of the CRC samples the latter only in codons 12 and 13.Using pyrosequencing, 46.4% of the 250 CRC cases were found mutated. Most mutations were located in codon 12 (36.4% from all cases) and several were located in codon 61 (3.2%). All mutation identified by PCR-RFLP were confirmed by pyrosequencing and, in addition, one more mutated sample was identified in the subset of 100 samples.Both methods are highly specific and can profitably be used in the molecular diagnosis of colorectal cancer in order to establish the adequate therapy.

Tumor infiltrating lymphocytes (TIL), as a microenvironment component were studied in various epithelial tumors, with contradictory results. Recent data about regulatory T-cells (Treg) revealed new explanations for pro- and anti-tumor implications of TIL. Tregs immunoprofile was recently completed with Foxp3 expression. A T-cell fraction (Th) is producing cytokine IL17 and is now considered acting in tumor progression. Our study aimed to analyze immunohistochemically (IHC) Foxp3+ and IL17 expression in resected lung adenocarcinomas, since they could become possible targets in the antitumor immunotherapy. The studied material was represented by paraffin-embedded tumor fragments from 59 patients with TIL identified on HE staining. The antibodies used were Foxp3 and IL17. The statistical analysis used logistical regression on SPSS19 software (Chicago, IL, USA). TIL was usually mild or scarce. A positive statistic correlation resulted between the amounts of TIL in peritumoral and intratumoral location but without correlation to histopathological grading. Foxp3 and IL17 were present in TIL lymphocytes, tumor cells and fibroblasts; IL17 was expressed also in periendothelial cells (PEC). Foxp3 positivity was significantly correlated for lymphocytes÷tumor cells, lymphocytes÷fibroblasts and tumor cells÷fibroblasts, suggesting their concerted action. Tumor cells and lymphocytes Foxp3 expression was inversely correlated with the amount of TIL. Between lymphocytic Foxp3 and PEC IL17, we found a weak negative correlation. The TIL had a quite positive correlation with PEC IL17. In these conditions, Foxp3 could be a mediator of the tumor cells inhibitory aggression upon the immune system and could be used as a molecular target for biological antitumor therapy.

Somatostatinoma is a rare neuroendocrine tumor which especially develops in the pancreas. There are few communicated cases about extra-pancreatic localization, having as a particularity the absence of somatostatin hypersecretion syndrome and frequent association with von Recklinghausen neurofibromatosis. We present the case of a 42-year old patient with Von Recklinghausen neurofibromatosis admitted in our clinic with a chronic upper digestive obstruction syndrome. The presence of a first jejunal loop somatostatinoma was an intraoperative surprising diagnosis that imposed jejunal resection and association of complementary specific treatment. Despite the therapeutic correct management, the status of the patient deteriorated very fast, confirming the aggressiveness of this neoplasia.

Type 1 neurofibromatosis associates various abdominal tumors as gastrointestinal stromal tumors, duodenal or pancreatic carcinoid, and adrenal tumors like pheochromocytoma. We present the immunohistochemistry report in two cases with different profile regarding the evolution. One case is a 7th decade women diagnosed with unilateral pheochromocytoma and GISTs, with a good prognosis after surgery. The other case is a 41-year-old male diagnosed with duodenal metastatic somatostatinoma after an intestinal occlusive syndrome and later the hormonal profile leaded to the diagnosis of pheochromocytoma. The patient had a fulminate evolution within six months from diagnosis.

Gastrointestinal stromal tumors (GISTs) are the most common primary mesenchymal neoplasias of the gastrointestinal tract, typically expressing c-kit (CD117) and CD34. Recently, it was reported that nestin and caveolin-1 are also expressed in some human sarcomas, GISTs included. We performed a retrospective study on formalin fixed, paraffin embedded samples from 81 cases of confirmed GISTs, aiming to characterize their immunohistochemical profile, including nestin and caveolin-1 expressions. Tissue samples were evaluated immunohistochemically for CD117, CD34, nestin and caveolin-1. The patients (M:F 36:45), aged 46 to 84 years, had spindle cell type GISTs in 56.7% of cases, epithelioid in 30.8% and mixed pattern in 12.3%. Immunohistochemically, CD117 was positive in 88.9% of GISTs, CD34 in 85.1%, nestin in 77.7% and caveolin-1 in 71.6% of the tumors. Of nine c-kit negative GISTs, 66.7% expressed nestin, the same as caveolin-1 and 44.5% expressed both nestin and caveolin-1. Statistical analysis using Kendall's and Spearman's tests revealed significant correlations between nestin and caveolin-1 expressions (p=0.024). Our results suggest that nestin and caveolin-1 could be considered sensitive markers in GISTs, together with CD117 and CD34, for diagnostic purposes. Their significant expression in CD117 negative GISTs could represent an immunohistochemical alternative in establishing the diagnosis of these tumors.

Malignant fibrous histiocytoma (MFH) is a tumor which has a mesenchymal origin, and an uncertain histogenesis. MFH with giant cell accounts for 3-15% of all malignant fibrous histiocytomas.To explore the histopathology, the diagnosis and the treatment of MFH with giant cell of larynx.We report a case of a glottic MFH at a 59-year-old male, who has been smoking for 30 years, and was hospitalized in June 2008 at Emergency County Hospital of Craiova.The largely-sized tumor was originated in glottic area, upper a left vocal cord, with no paresis. The tumor determined respiratory failure and dysphonia. Patient underwent surgical excision of the tumor after an emergency tracheotomy. The immunohistochemical techniques proved positive for vimentin, smooth muscle actin, CD68, CD34, bcl2, EGFR, S100, Ki67, and negative for CD117, NFT, chromogranin, c-erbB2, CK34betaE12, MNF116, and p53.Malignant fibrous histiocytomas (MFH) with giant cell of larynx are very rare mesenchymal neoplasm (this case seems the first reported). The diagnosis of MFH of larynx was difficult and the immunohistochemistry could have been helpful.

Detection of the esophagogastric junction adenocarcinoma in symptomatic stage determine a low survival. The aim of the study was to identify the prognostic factors after eso-gastrectomy for esophagogastric junction adenocarcinoma. There was done a prospective study of a 43 patients with esophago-gastric resections and abdomino-mediastinal lymph nodes dissection between 2001 and 2006 at the General and Esophageal Surgery "St. Mary" Clinical Hospital: 25 patients with transhiatal total gastrectomy, 6 patients with total gastrectomy and distal esophagectomy by separated incisions, abdominal and thoracic, 3 patients with total gastrectomy and subtotal esophagectomy by abdomino-cervical approach, 9 patients with subtotal esophagectomy by abdomino-cervical approach with cu small gastric curvature resection, radical resections in 22 patients. The patients were followed by clinic, endoscopic, TC exam and tumoral markers. There were done complex statistic analysis using SPSS 16.0. The mean interval of the surveillance was 24 months (6 - 60 months). 1 year survival was 77,74%. Long-term survival was influenced by age (p_value = 0.0129), tumoral grading (p_value = 0.0297), the number of lymph nodes metastasis (p_value = 0.0029) and pT stage (p_value = 0.0139), and was not dependent on Siewert type, ASA class, surgical approach, resection type, the number of the dissected lymph nodes, abdominal or mediastinal. In locally advanced esophagogastric junction adenocarcinoma, the frequency of lymph nodes metastasis (81%) especially in patients with tumoral type III and unfavorable results of surgical treatment as unique therapeutically method show the necessity of a multimodal approach pre and post-operatory by using selection methods with a good prediction of neoadjuvant treatment.

Pseudo-achalasia is a rare pathologic entity that mimics idiopathic achalasia, usually secondary to malignant infiltration of the cardia. Its significance is related to the fact that it may be difficult to distinguish from primary achalasia; the outcome and therapeutic course are different. In fact, a large variety of processes may be responsible for the development of a secondary achalasia syndrome; we present a case with pseudo-achalasia due to a middle thoracic esophageal squamous cell carcinoma.

A small percentage of ovarian neoplasms are transitional cell tumors, which proves to be a distinct group with various histological and immunohistochemical patterns. In this study, 13 archived formalin-fixed paraffin-embedded samples of transitional cell tumors of the ovary have been assessed using standard HE stain and the indirect tristadial ABC peroxidase IHC method for 11 antibodies (CA125, CK7, CEA, EMA, MNF116, CK20, Vim, ER, PgR, PCNA, Ki-67). More than 50% were malignant Brenner tumors. CA125 was positive in all malignant tumors (of Brenner type and transitional cell carcinomas), but not in benign and borderline tumors, while CK7 was positive in approximately 70% of all cases. These two antibodies have shown a high sensitivity and low specificity, but do not correlate to each other. PCNA was positive in the study batch with a mean value of 40% and Ki-67 with a mean value under 25%. A direct correlation statistically significant has been noted between the aforementioned proliferation factors and the tumor grade (r = 0.4, p = 0.05). The other markers were unspecific, with low sensitivity and independently of the histopathological type.

Krukenberg-type tumors (KT) are rare among ovarian metastases, but responsible for the most frequent diagnostic confusions with ovarian cancer. They are peculiar: uncertain pathogenesis, challenging etiological diagnosis, poorer prognosis for the primary. We studied 9 cases, with a mean age of 52 years, operated since 2001; no case was discovered as a result of prophylactic oophorectomy. Timing of TK diagnosis: 3--metachronous, 4--synchronous, as incidental discovery and 2--retrospective pathological diagnosis. Site of primary: 3--gastric, 5--colonic or appendiceal, 1--breast. Imaging appearance was useful only if interpreted in clinical conditions. Morphology: 7/9 bilateral, solid or mixed gross appearance, oval, mean diameters 9.4/7.8 cm. Microscopy: in 8 KT of digestive origin, 3--signet-ring cell carcinoma, 3--mucinous adenocarcinoma, 2--mixed pattern; 1 KT or breast origin was diagnosed by immunohistochemistry; 6/9 presented microscopic peritoneal despite a lack of strong correlation with the appearance of carcinomatosis or cytology of ascites. Survival: 3--no evidence, 5--disease-free after 4-13 months, 1--survived 2 years after debulking (4 years after colectomy). Clinical, evolutive and prognostic features of KT are determined by the biologically behavior of the primary (rapid lymphatic and hematogenous spread to the ovary), so the benefit of surgery is limited. Bilateral ovarian tumors, particularly in premenopausal women, must raise a high index of suspicion for KT, before or during surgery; diagnosis is a team challenge.

The aim of the work paper is to present the diagnosis methods of the esophago-gastric junction adenocarcinoma, based on our experience and literature data. The later reveal many novelties about diagnosis means in Barrett's esophagus (BE), the definition and classification of BE, as well as the progress of the endoscopical, immunohistochemical and molecular methods in surveillance of the dysplasia arising in BE and in detection of intraepithelial neoplasia. Early esophago-gastric junction (EGJ) adenocarcinoma (AC) is asymptomatic and its detection may be possible only through endoscopical surveillance. Although endoscopical surveillance is widely practiced, early AC represents only 20% from AC arising in BE. For this reason is necessary to use some more precise methods for identifying intestinal metaplasia on distal esophagus, in patients with gastro-esophageal reflux disease, as well as for risk stratification in patients with dysplasia and for detection of intraepithelial neoplasia. Applying modern methods of immunohistochemical and molecular diagnosis on endoscopical biopsy or esophageal brushing samples, the diagnosis rate for BE, dysplasia and early AC is improved and using the imaging means permits to obtain preoperative TNM staging and tumoral type (Siewert), with implications in therapeutical management.

Bilateral breast cancer is uncommon and difficult to define because it may manifest as simultaneous, synchronous or metachronous tumours. The true clonal origin and biologic behaviour are still controversial. Following a right breast contusion, bilateral breast tumours were diagnosed in a 74 old female patient; the left one, neglected for 3 years, typically scirrous; the right one with cystic, pseudo-inflammatory appearance. Sonography and fine-needle cytology concluded: left, carcinoma (T3bN1Mx); right, benign nodule with traumatic hematoma. Three sessions of chemotherapy were followed by simultaneous left Madden mastectomy and right simple mastectomy (frozen sections negative for malignancy). Histopathology: left, invasive lobular carcinoma (ypT4N0Mx); right, micropapillary invasive carcinoma mixed with adenoid cystic carcinoma. After another 3 chemotherapeutic sessions, right axillary lymphadenectomy was performed. Both lesions were evaluated by immunohistochemistry and the TNM pathological classification was reconsidered; left, ypT4N1Mx; right, ypT3N0Mx. Considering the natural history, histopathological and immunohistochemical patterns of the two tumours, these seem to be distinct but shearing a common favourable biologic behaviour. No genetic studies were performed in the absence of specific risk factors. Based on clinical, epidemiologic, morphologic and genetic evidence, bilateral breast cancers (synchronous or metachronous) are considered to be a special evolutive entity of breast cancer. Our case suggests that, in the absence of risk factors for bilaterality of breast carcinoma: description of bilateral breast cancers based on diagnostic chronology of the two tumours is arbitrary; they may occur sporadically and have independent evolution; their biology rather resembles a multiple primitive malignancy than a true bilateral breast cancer.

The objective of the paper was to observe the ultrastructural aspects of the endometrial biopsies taken from female patients at post-menopause with substitutive hormonal therapy (TSH). Material and methods. A number of three endometrial biopsies were taken from female patients at post-menopause with TSH. The ultrastructural analysis was carried out with the help of the electronic microscope Philips ME 301 using classical electronic microscopy methods. Results and discussions. The ultrastructural analysis has highlighted the presence of cuboidal and columnar epithelial cells, with basally situated nuclei, well represented cellular organelles, some cells having at the apical pole microvilli. At the electronic microscope, three types of epithelial cells are described, at the level of the endometrial mucosa of the woman who is in a fertile period: secretory cells (cells with an average electronic density with microvilli on the luminal surface), ciliated cells and clear cells (cells with a low electronic density). These cells have certain ultrastructural characteristics and of receptivity towards the steroid hormones. The stroma is axial with elongated cells with oval nuclei, with nucleoli and with smooth or undulated membrane. Conclusions. The ultrastructural aspects suggest the presence at endometrial level of epithelial active glandular cells, secretory cells and stromal active cells at female patients at post-menopause with TSH.

To quantify the apoptotic phenomenon on endometrial biopsies in postmenopausal patients under hormonal replacement therapy (HRT).The study lot consisted of 30 endometrial biopsies on which we studied the apoptotic phenomenon through morphological and molecular biology techniques (TUNEL reaction). Examination of endometrial biopsies before and post-therapeutically has been made.From morphological point of view, pre-therapeutically, endometrial biopsies presented apoptotic changes in about 1-3% of cells and under TSH there have been observed apoptotic changes in about 1-2% of cells. In female reproductive system, we found out a raised rate of cellular proliferation and concurrently a raised rate of apoptosis. Apoptotic phenomenon can be observed in endometrium at every menstrual cycle. In proliferative endometrium apoptosis rate is low, but in endometrial carcinoma apoptosis rate grow up. Bcl2 and Bax are expressing in normal and hyperplastic endometrium, but in endometrial carcinoma Bcl2/Bax ratio decline.Quantification of apoptosis, using morphological and TUNEL reaction methods, on endometrial biopsies in postmenopausal patients before and after therapy indicate a low rate of apoptotic phenomenon.

Understanding of the pathogenesis, diagnosis, and treatment of lower GI bleeding has drastically changed during the last 50 years, but it continues to be a frequent cause of hospital admission and also a factor in hospital morbidity and mortality. Acute lower gastrointestinal hemorrhage (ALGIH) represents only 20% of the GI bleeding and the small intestine is the site of hemorrhage in about 1% of cases. Although in the last four decades, diagnostic methods for locating the precise bleeding point improved greatly, still the adequate localization of the lesion is very difficult to achieve through algorithmic approaches. We performed a clinical study and we retrospectively analyzed 5 patients (mean age = 59,8 years, 1 female) who had a surgical intervention for acute lower GI hemorrhage in the last decade, in order to emphasize diagnosis difficulties when the bleeding arises from small lesions in the small bowel that is not easily accessible for direct visualisation. Surgery was the treatment of choice in every case consisting in segmental resections of the involved small bowel, along with viscerolysis and exploratory gastro-jejunostoma. The mortality rate was 20% (1 postoperative death of cardiac etiology). There have been no specific postoperative complications in the other four patients and a good outcome was reported. The diagnosis is particularly difficult and when colonic and upper gastrointestinal evaluations fail to identify a source of bleeding, a small intestinal source should be considered. We can conclude that the most important factor in the management of ALGIH is determination of specific localization of the lesion.

Anal carcinoma is rare; fistula-in-ano is sometimes mentioned among other premalignant conditions. Chronic anal fistula is associated with malignant transformation to mucinous adenocarcinoma, difficult to diagnose in the anal region and associated to a poor prognosis. Malignant transformation to infiltrating colloid carcinoma was surprised during a one year period, in a patient with long-standing perianal fistula (24 years). Inflammatory changes of the perineal region and other peculiar characteristics (such as neoplastic spread following supurative pathways) were responsible for diagnostic and surgical difficulties.

We report on a cirrhotic patient, with history of colecistectomy, admitted for acute digestive bleeding. Esogastric causes were excluded by endoscopy; due to continuous hemorrhage, the patient was operated in the next 20 hours. The cause was established during the operation; solitary omfalo-enteric varices, with active vascular fistula. Preoperative etiology of acute intestinal bleeding may be difficult to establish, sometimes even during the surgical intervention. We comment upon rare causes of acute intestinal bleeding, mainly ectopic varices determined by portal hypertension.

A non-specific esophagitis developed in a young male, apparently determined by heavy abuse of alcohol. Shortly after, a stenotic pseudo-tumoral mediothoracic esophageal lesion was diagnosed. Although there was a high index of suspicion regarding the caustic origin of the lesion, cancer could not be excluded using current diagnostic methods. Temporary feeding jejunostomy was followed by uneventful total esophagectomy and gastric pull-up. Pathologic examination of the resected specimen was a surprise, revealing an esophageal ulcer based on massive severe non-specific esophagitis. Retrospectively, the ulcer was judged as primitive or idiopathic. We discuss some etiopathogenic aspects of common secondary esophageal ulcers (related or not to reflux disease), in contrast with idiopathic esophageal ulcers.

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms with uncertain prognosis. Distant metastases are most commonly found in the liver, followed by the lungs and bones. We report one case of a 50-year-old female who presented with diffuse abdominal pain. Ultrasonography showed small bowel obstruction by a lesion of 10 cm in diameter. Segmental jejunal resection was performed with removal of a well-circumscribed submucosal mass, with solid and cystic areas and foci of hemorrhage. Surgery also revealed a nodule in the recto-uterine pouch, a firm tumor in the left ovary, and multiple diffuse nodules in the omentum. Histopatho-logical examination showed mixed pattern of spindle and epithelioid cells, with dense cellularity, high nuclear pleomorphism, 2 mitoses per 50 high-power fields, necrosis and rich vascularization. Immunohistochemical analysis showed diffuse positive staining for CD 117 and VIM. Tumor cells were consistently negative for actin, CD34 and S-100. Based on the above findings, the diagnosis was mixed type malignant GIST of the small intestine with multiple metastases in the pouch of Douglas, ovary and omentum. Histologic subtype, tumor size and site are the most important features in malignant behavior. Mitotic count proved to be less significant. Making the right diagnosis is crucial for patients.