Official Journal of the Romanian Society of Physiological Sciences

CHIEF EDITOR
CO-CHIEF EDITORSASSOCIATE EDITORSEXECUTIVE EDITORSFRANCISC SCHNEIDERIOANA SISKACARMEN TATUMIHAI NECHIFORSORIN RIGA
FLORINA bOjIN
GAbRIELA TANASIEDACIANA NISTORCALIN MUNTEANEDITORIAL BOARD
ARDELEAN AURELBADIU GHEORGHEBĂDĂRĂU ANCA
BENEDEK GYÖRGYBENGA GHEORGHEBUNU CARMEN
COJOCARU MANOLECUPARENCU BARBUCONSTANTIN NICOLAE
HAULICĂ ION
IANCĂU MARIAMIHALAŞ GEORGETA
MUNTEAN DANINAMUREŞAN ADRIANANESTIANU VALERIUOPREA TUDOR(Arad)(Constanţa)(Bucureşti)(Szeged)(Cluj)(Timişoara)(Bucureşti)(Oradea)(Bucureşti)(Iaşi)(Craiova)(Timişoara)(Timişoara)(Cluj)(Craiova)(New Mexico)PĂUNESCU VIRGILPETROIU ANA
POPESCU LAURENŢIU
RÁCZ OLIVERRIGA DANSABĂU MARIUS
SIMIONESCU MAIA
SIMON ZENOSAULEA I. AURELSWYNGHEDAUW BERNARDTANGUAY M. ROBERTTATU FABIAN ROMULUS
VLAD AURELIANVOICU VICTORZĂGREAN LEON

(Timişoara)(Timişoara)(Bucureşti)(Košice)(Bucureşti)(Tg. Mureş)(Bucureşti)(Timişoara)(Chişinău)(Paris)(Canada)(Timişoara)(Timişoara)(Bucureşti)(Bucureşti)AccREDITED By cNcSIS - B+cATEgORy - cODE 240
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Fiziologia(80)‑ Physiology 2010supplement
2013.24.4
2014.24.3(83)
 Fiziologia- Physiology

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Official Journal of the Romanian Society of Physiological Sciences

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Fiziologia- Physiology 2014.24.3
2013.24.4(83)(80)
Fiziologia‑ Physiology 2010supplement

STNETNOC
4................................................................................... recnaC fo skramllaH eht gniylrednU erucsbO revewoH ,romuT fo stnatibahnI – stsalborbiF detaicossA-recnaC :weiveR .1
C ucsetianaP ,V ucsenuaP ,G eisanaT ,M acieD ,F nijoB ,L tanreC
31.................................... sitirhtrA decudnI-tnavujdA fo ledoM taR a ni ecnalaB tnadixoitnA-tnadixO eht no sdicA yttaF detarutasnuyloP 3-agemO dna nituR fo stceﬀE ehT .2
A naşeruM ,D dalV ,R navodloM ,D utsopA ,C uicacoS ,A notraM ,CI şihC ,D uratlaB

CONTENTS

81.................................................................. staR ni stceﬀE evitcetorpoidraC trexE dna aixopyH cirabopyH fo stceﬀE eht esreveR nasotihC dna murabraB muicyL ,nitecreuQ .3
P afloB ,G azroB ,D dalV ,R navodloM ,A notraM ,A naşeruM ,CI şihC ,A icivortimuD
32........................................................................................................................................ yhtapolahpecnE citapeH fo ygolohtapoisyhP eht ni lotisonI-oyM fo ecnatropmI ehT .4
IA uărădăB ,AD noI ,R aecocapaP ,C ienroiC ,M aenuB ,M răzaL ,C uaehcS

CONTENTS

62............................................................................................................................................ ksiR ralucsavoidraC fo noitacﬁitartS eht ni ecnacﬁingiS citsongorP :erusserP esluP .5
S șacnaM ,A rimogarD ,G ucsenoI ,D aţâbiâB
13....................................................................................................................... skramdnaL lacimehcotsihonummI dnA lacigolotsiH - amorbﬁoignA laegnyrahposaN elinevuJ .6
D tahroH ,S aeblutoC ,M atumoD ,MR narihG ,G ucsenavoI ,FD aediG

1. Review: Cancer-Associated Fibroblasts – Inhabitants of Tumor, However Obscure Underlying the Hallmarks of Cancer ...................................................................................4
1.
The
Osteoporosis
Predisposing
in Femoral Proximal Epiphysis Fractures......................................................................................4
Review:
Metformin-From
Diabetes
to–Cancer
TherapyCFactors..............................................................................................................................................................4
Cernat
L,Pathophysiology
BojinF, Deica M, ofTanasie
G, Paunescu
V, Panaitescu
DeicaC,M,
Sima R,M,Cernat
L, Bojin
F, Tatu
C, Tanasie
G,Panaitescu C, Paunescu V
Miu
HurmuzUngureanC, MiuL, TatuF
53........................................................................................................................................................................................................... sitilucsaV yranomluP eht otni thgisnI weN .7
MI uracojoC ,DC eibarV ,E usuR ,M uracojoC
83............................................................................................................................................................................. ?gnihT laeR a tI sI ,yhtaporueN citpO detaicossA enoradoimA .8
I goloZ ,M naetnuM ,N ucseluciN

SNIRPUC

4................................................................................................................................................. recnac ni uirotinﬁed lor uc elaromut etnenopmoC – elaromutirep eletsalborbiF .1
C ucsetianaP ,V ucsenuaP ,G eisanaT ,M acieD ,F nijoB ,L tanreC

31............................................... tnavujda ed ăsudni ătirtra uc inaloboş al iţnadixoitna-iţnadixo ieţnalab arpusa 3-agemO iţarutasenilop işarg rolizica la iş iulunituR lutcefE .2
A naşeruM ,D dalV ,R navodloM ,D utsopA ,C uicacoS ,A notraM ,CI şihC ,D uratlaB

2. The Eﬀects of Rutin and Omega-3 Polyunsaturated Fatty Acids on the Oxidant-Antioxidant Balance in a Rat Model of Adjuvant-Induced Arthritis ....................................13
2. AAdipose-Tissue
DerivedStem
Cells: State ofon
thethe
ArtQuality
Tissue ofEngineering.................................................................................................................................11
2.
Review
Influenceof Malocclusion..............................................................................................................................................9
Baltaru
D, ChişonIC,the
MartonA, Socaciu
C, Apostu D, Moldovan
R, Vlad D,Life.
MureşanA
Hurmuz
M,
Bojin
F,
Miu
C,
Ungurean
C,
Tatu
C,
Ionac
M,
Tatu
F
Raescu M, Lambescu DG, Nuca C, Funieru C, Jumanca D
3. Quercetin,
Lycium Barbarum
and ChitosanEffects
ReverseontheActiveEﬀectsBehaviorsof Hypobaric
Hypoxiaand Exert
CardioprotectiveEﬀects in Rats ..................................................................18
3.
Human Recombinant
Inteferon-Alphain theRat Forced
Swimming
Test.....................................................................................17
3.
Motivationalof
Orthodontic...............................................................................................................................................................13
Dumitrovici
A, ChişCharacteristicsIC,MureşanMartonA, Moldovan
R, VladD, Borza G, Bolfa P
Zahiu
D, Goganau
I, Braga
RI,A,Baca
L, Zagrean
LPatients.
Lambescu DG, Patrichi B, Cosconel CI, Nica L, Galuscan A
Importance
Myo-Inositol
in thePhysiopathology........................................................................................................................................23
4. TheCortical
ActivityofandHeart Rate
Changes
as MarkersofofHepatic
NoxiousEncephalopathy
Stimulation Response
during Chloral Hydrate Anesthesia ...................................................22
4.
Tumor
Necrosis
Factor
Evaluation
Casting
Pavel
B,C,DăneasaCălinM,
A,CiorneiRădulescu
Am,
RoscaAe,Braga
Ri, LaserZahiu
D, ZăgreanCo-Cr
L Alloys..........................................................................................................16
ScheauLazăr M,A,Bunea
C, forPapacocea
R,and
Ion SelectiveDA,Bădărău
AI Sintering
Pop D, Rusu LC, Sinescu C, Negrutiu ML, Galuscan A, Jivanescu A
5.
Arguments
forPrognostic
Using Thrombelastography
in thecation
StudyofofCardiovascularHemostasis Comparedto Other Laboratory Tests .........................................................................26
5. Pulse
Pressure:
Signiﬁcance in the Stratiﬁ
Risk ............................................................................................................................................26
Oniceanu
FM,IonI,
Adumitresi
C,Radulescu
N,
FarcasC,
Stefanescu
AC,
ChiricaR
5.
18-FDG-PET
andG,PET/CT
Bâibâţa
D, Ionescu
DragomirforA,Minimal
Mancaș SInvasive Diagnosis of Head and Neck Cancer...................................................................................................................20
Canjau S, Sinescu C, Negrutiu M, Rusu L, Todea C
6. Patient Related Prognostic Factors and Therapeutic Strategy in Larynx Squamous Cell Carcinoma.........................................................................................31
6. Juvenile Nasopharyngeal Angioﬁbroma - Histological And Immunohistochemical Landmarks .......................................................................................................................31
Prodea M, Horhat D,Balica N, Boruga O, Poenaru M
Gidea
IovanescuofG,Obstructive
Ghiran RM,Nasal
DomutaM, Cotulbea
S, Horhat
D
6.
TheDF,
Incidence
Pathology
among
the Patientswith Sleep Apnea Syndrome..............................................................................................26
Budu
VA
7. In VitroCharacterisation of Tumor-AssociatedFibroblastsfromDifferent Solid Tumors..............................................................................................................35
7. New L,Insightthe Pulmonary
Vasculitis...........................................................................................................................................................................................................35
CernatBojininto
F, Deica
M, Anastasiu
D, Tanasie
G, Ilina R, Paunescu V, Panaitescu V
Cojocaru
M,
Rusu
E,
VrabieCD,
Cojocaru
IM
7. Effectiveness Assessment Criteria for CT Diagnosis in Mediastinal Lymphatic Extension of the Lung Cancer............................................................................29
8. Comorbidities
Cipu
D, Cipu DS and Risk Factors in Heart Failure with Preserved Ejection Fraction...................................................................................................................39
MavreaA, BucurA, Tomescu
8. Amiodarone
AssociatedOpticMNeuropathy, Is It a Real Thing? .............................................................................................................................................................................38
Niculescu N, Muntean M, Zolog I
81............................ naloboş ed ledom nu-rtnî rotcetorpoidrac snupsăr nu ăticrexe iş erabopih ieixopih eletcefe ăzaeracartnoc lunasotihC iş murabraB muicyL ,lunitecreuQ .3
P afloB ,G azroB ,D dalV ,R navodloM ,A notraM ,A naşeruM ,CI şihC ,A icivortimuD

32............................................................................................................................................................... ecitapeh ieitapolafecne aigolotapoizﬁ nî iululotizoni-oim aţnatropmI .4
IA uărădăB ,AD noI ,R aecocapaP ,C ienroiC ,M aenuB ,M răzaL ,C uaehcS
62................................................................................................................................... ralucsavoidrac iulucsir aeracﬁitarts urtnep acitsongorp aitacﬁinmes :iuluslup aenuiserP .5
S șacnaM ,A rimogarD ,G ucsenoI ,D aţâbiâB
13...................................................................................................................................... ecimihcotsihonumi iş ecigolotsih icitsirecarac – linevuj naignirafosan lumorbﬁoignA .6
D tahroH ,S aeblutoC ,M atumoD ,MR narihG ,G ucsenavoI ,FD aediG
53........................................................................................................................................................................................................................ ăranomlup atilucsav nî iţătilautcA .7
MI uracojoC ,DC eibarV ,E usuR ,M uracojoC

83................................................................................................................................................................ ?etatilaer o etse – anoradoima uc iulutnematart ătaicosa aitaporueN .8
I goloZ ,M naetnuM ,N ucseluciN3ygoloisyhP - aigoloiziF  )77( 1.32.3102

CUPRINSCUPRINS

1.
Metformin: dela diabet la– terapiaantitumorală
1. Fibroblastele
peritumorale
Componente tumorale.......................................................................................................................................................................4
cu rol deﬁnitoriu in cancer .................................................................................................................................................4
1.
Fiziopatologia
osteoporozei
inC fracturile
epifizei Vproximale a femurului................................................................................................4
Deica
M,
Sima
R,
Cernat
L,
Bojin
Tatu
C,predispozantiTanasie
G,Panaitescu
C, Paunescu
Cernat L, Bojin F, Deica M, Tanasie–G,F,factori
Paunescu
V, Panaitescu
Miu C, Hurmuz M, Ungurean C, Miu L, Tatu F
2.
CeluleleRutinului
stem derivate
din ţesutuladipos:
actualităţiîningineriatisulară
.................................................................................................................................11
2. Efectulşi al acizilorgraşi polinesaturaţi
Omega-3 asupra balanţei oxidanţi-antioxidanţi
la şobolani cu artrită indusă de adjuvant ...............................................13
HurmuzM,asupra
Bojin F,influentei
Miu C, Ungurean
C, TatuasupraC, Ionac
M, Tatuvietii.
F .....................................................................................................................................................92.
Review
malocluziilor
calitatii
Baltaru D, Chiş IC, Marton A, Socaciu C, Apostu D, Moldovan R, Vlad D, Mureşan A
Raescu M, Lambescu DG, Nuca C, Funieru C, Jumanca D
3. Efecteleinterferonului-alfa recombinant umanasupracomportamentelor active la testulînotuluiforţat, la şobolan ...............................................................17
3. Quercetinul,
LyciumBarbarumşi Chitosanulefectele hipoxiei hipobare şi exercită un răspuns cardioprotector într-un model de şobolan ............................18
Zahiu
D, Goganau
I, Braga
RI, Baca
L, Zagreancontracarează
L
3.
Caracteristicile
motivationale
ale pacientilor
cu tratament
ortodontic.....................................................................................................................................13
Dumitrovici
A, Chiş IC,Mureşan A, Marton
A, Moldovan
R, Vlad D, Borza
G, Bolfa P
Lambescu
DG,
PatrichiB,
Cosconel
CI,
Nica
L,
GaluscanA
4. Modificărileactivităţii corticale şialeritmuluicardiac ca markeri ai răspunsului la stimulareanociceptivăîntimpulanestezieicucloralhidrat.............................22
4. Importanţa
mio-inozitoluluiîn ﬁziopatologia
encefalopatiei
PavelB, Dăneasa
A, Călin A, Rădulescu
Am, RoscaAe,
Braga hepatice
Ri, Zahiu...............................................................................................................................................................23D, Zăgrean L
4.
Evaluareade Co-Cr
ScheauC, Lazărfactorului
M, BuneadeM,necroza
Ciornei C,tumorala
Papacoceapentru
R, Ion aliajele
DA, Bădărău
AI obtinute prin turnare si sinterizare laser............................................................................16
5. Argumentepentruutilizareatrombelastografieiînstudiulhemostazeicomparativ
cu alteteste de laborator .............................................................................26
Pop
D, Rusu LC, Sinescu C, Negrutiu ML, Galuscan A, Jivanescu A
Oniceanu
I, Adumitresi
Farcasstratiﬁ
C, Stefanescu
AC, Chirica
R
5. PresiuneaFM,Ion
pulsului:semniﬁcatiaC,Radulescu
prognosticaN,pentru
carea riscului
cardiovascular...................................................................................................................................26
5.
Diagnostic
minim
invaziv alA,cancerului
Bâibâţa
D, Ionescu
G, Dragomir
Mancaș S de la nivelul capului si gatului utilizand 18-FDG-PET si PET/CT ...................................................................................20
6. Factoride prognosticlegaţiM,deRusu
pacientşistrategiiterapeuticeîn carcinomullaringian cu celulescuamoase .............................................................................31
CanjauS, Sinescu
C, Negrutiu
L, Todea C
Prodea M, Horhat D,Balica N, Boruga O, Poenaru M
6. Angioﬁbromul nasofaringian juvenil – caraceristici histologice şi imunohistochimice ......................................................................................................................................31
6.
Incidenta
patologiei
obstructive
nazalerandul S,populatiei
cu sindrom
de apneein somn.
....................................................................................................26
Gidea
DF, Iovanescu
Ghiran
RM, Domuta
M,inCotulbea
Horhat7.
Caracterizare
in G,
vitro
a fibroblastelorperi-tumoraleizolateDdindiferite tumori
solide............................................................................................................35
Budu
VA
Cernat L, Bojin F, Deica M, Anastasiu D, Tanasie G, Ilina R, Paunescu V, Panaitescu V
7. Actualităţi în vasculita pulmonară ........................................................................................................................................................................................................................35
Cojocaru
M, Rusu
E, Vrabie
CD,IM
7.
Evaluarea
eficientei
criteriilor
de diagnostic
computer tomografic
diagnosticarea extensiei
limfoganglionare mediastinale a cancerului bronhopulmonar.......29
8.
Comorbidităţişifactorii
deCojocaruriscîninsuficienţacardiacă
cu fracţie deinejecţieprezervată
..............................................................................................................39
MavreaA, Bucur
Cipu
D, Cipu
DS A, Tomescu M
8. Neuropatia asociată tratamentului cu amiodarona – este o realitate? ................................................................................................................................................................38
Niculescu N, Muntean M, Zolog I
2014.24.3(83) 
Fiziologia - Physiology
2013.24.4
2013.23.1 (80)(77) 
 Fiziologia - Physiology

333

THE PATHOPHYSIOLOGY OF OSTEOPOROSIS – PREDISPOSING
FACTORS IN FEMORAL PROXIMAL EPIPHYSIS FRACTURES
CATALIN MIU1, MIHAI HURMUZ2, CALIN UNGUREAN3, LUMINITA MIU4, FABIAN TATU2
1First Department of Anatomy-Embryology, “Victor Babeş” University of Medicine and Pharmacy, Timişoara
2
Department of Orthopedics-Trauma-Urology and Imagistics, University of Medicine and Pharmacy “Victor Babes” Timisoara
3
Emergency Military Hospital “Dr. Victor Popescu”, Timişoara
4
Radio-Imaging Center Telescan, Timişoara

ABSTRACTThe anatomoclinical study was conducted on patients belonging to three age groups and consisted in measuring the bone densityof the femoral head, the femoral neck and the area of the greater trochanter.
The object of the study was to assess the degree in which a poor quality of the bone substance is correlated with age and, implicitly,with osteoporosis, making the areas of the femoral proximal epiphysis more susceptible to bone mass loss.
The upper femoral epiphysis was divided into three areas: the femoral head, the femoral neck, the greater trochanter. Research
consisted in measuring bone density of the femoral proximal (upper) epiphysis, using a CT scan (unenhanced pelvic CT scan)
expressed in Hounsfield Units (HU).
Ageing leads to a higher incidence of trochanteric fractures vs. femoral neck fractures. A female patient suffering from a trochantericfracture is older and has a more severe osteoporosis than a female patient suffering from a femoral neck fracture. The anatomic
characteristics of this region - the femoral proximal epiphysis - and the amount of cancellous bone which is more severely affectedby osteoporosis are essential predisposing factors of the two major post-traumatic pathological entities in this area: femoral neckfractures and greater trochanteric fractures.
Key words: femoral head, femoral neck, grater trochanter, osteoporosis

INTRODUCTION
The incidence of hip fractures is continually growing, representing approximately 30 per cent of the fractures hospitalised in
the ER. It is a public health problem occurring in elderly patientswith associated disorders, and severely aggravates the functional
impairment already caused by the fracture.
Femoral proximal epiphysis fractures can be divided into femoral
neck fractures and trochanteric fractures. These two entities require totally different therapeutic approach; hence the necessity ofa study that quantifies the degree in which bone substance quality
may influence the occurrence of one or the other fracture patterns.
Osteoporosis being the main underlying factor for femoral proximal
epiphysis, the study focused on female patients who suffered fromsuch fractures and on the impact the quality of bone structure
has on triggering this pathology, everything correlated with theanatomic areas of the femoral proximal epiphysis.
The anatomoclinical study was conducted on patients belonging to three age groups and consisted in measuring the bonedensity of the femoral head, the femoral neck and the area of
the greater trochanter.
MATERIAL AND METHODS
Femoral proximal epiphysis fractures represent a significant

percentage of the lower limb pathology. Besides post-traumatic
fractures which may occur at any age, the fractures of elderly
people, which are extremely common, raise major problems
representing a challenge both for the patient and for the publichealth system.
Major progress has been made in the various methods ofsurgical treatment, arthroplasty being the therapeutic method of
choice in femoral neck fractures, while dynamic implants (DHS,
Gamma nail) represent the “golden standard” for trochantericfractures.
The results of the surgical treatment are associated witha functional recuperation strategy adapted to each patient.
When hospitalizing a patient with proximal femoral fracture
one has to consider the social and family reintegration of
the patient.
The accurate assessment of the various factors involved in theoccurrence of these fractures requires extensive epidemiologic,
clinic-statistical, anatomoclinical and anthropometric studies.
There is a tight connection between osteoporosis-induced
rarefying bone mass and the risk of fracture.
The first step in establishing an adequate approach andsolution of this pathology is assessing the degree to which thequality of the bone substance of the femoral proximal epiphysis
can influence fracture patterns.
Thus, the treatment of a patient with femoral proximal

Received 16th of July 2014. Accepted 10th of August 2014. Address for correspondence: Conf. Dr. Fabian Tatu, Department of Orthopedics-Trauma-Urology andImagistics, University of Medicine and Pharmacy “Victor Babes” Timisoara, Pta. E. Murgu No. 2, RO-300041 Timisoara, Romania, phone/fax: +40256490507, e-mail:fabitatu@gmail.com

4

Fiziologia - Physiology  2014.24.3 (83)

epiphysis fracture is a pluridisciplinary process: the orthopaedic
surgeon – for surgical healing, kinesiotherapy and balneology –for post-operative care, recuperation and reintegration, as well as
all the physicians specialised in bone pathology and the calcium
phosphorus metabolism.
The incidence of hip fractures is continually growing, representing approximately 30 per cent of the fractures hospitalised in
the ER. It is a public health problem occurring in elderly patientswith associated disorders, and severely aggravates the functional
impairment already caused by the fracture.
Femoral proximal epiphysis fractures can be divided into
femoral neck fractures and trochanteric fractures. These twoentities require totally different therapeutic approach; hence thenecessity of a study that quantifies the degree in which bone
substance quality may influence the occurrence of one or theother fracture patterns. Osteoporosis being the main underlying
factor for femoral proximal epiphysis, the study focused on female
patients who suffered from such fractures and on the impact
the quality of bone structure has on triggering this pathology,
everything correlated with the anatomic areas of the femoral
proximal epiphysis.
A prospective study was conducted between February 2013
– September 2013, on three groups of 25 patients each, divided
according to age-groups: < 40 year-old, between 40 – 60 yearold, and > 60 year-old.
Research consisted in measuring bone density of the femoral
proximal (upper) epiphysis, using a CT scan (unenhanced pelvic
CT scan) expressed in Hounsfield Units (HU).
The object of the study was to assess the degree in which apoor quality of the bone substance is correlated with age and,
implicitly, with osteoporosis, making the areas of the femoral
proximal epiphysis more susceptible to bone mass loss.
The upper femoral epiphysis was divided into three areas:
the femoral head (1), the femoral neck (2), and the greater
trochanter (3).

Fig.1. Bone density was measured on unenhanced pelvic CT scans
for all the three areas.

Fig. 2. Measuring bone density of the femoral head – 30-year-old
female patient.

Fig. 3. Measuring bone density of the femoral neck – 72-year-old
female patient.
2014.24.3 (83)  Fiziologia - Physiology

5due to the higher amount of cancellous bone in this area. The
decrease is more severe due to the bone mass loss induced bypost-menopausal osteoporosis characteristic for this age-group.

Fig. 4. Measuring bone density of thegreater trochanter – 27-year-old
female patient.

The average of the measurements in the three areas/eachstudy group were summarised in the table below (bone density
was measured in Hounsfield units and converted in gr/cm³).
Table I. Measured bone densities
HU
area 1

area 2

area 3area 1

area 2

area 3224.67159.201.194880.83034

0.699440 - 60 373.40

194.24128.381.12780.769480.63776>60

160.95103.851.052960.70290.5887335.98The loss of bone mass in the area of the greater trochanter ismore severe due to more advanced osteoporosis (both senile
osteoporosis and post-menopausal osteoporosis).

gr/cm3406.94<40

Fig. 6. The values of bone density measured in the study group 40 60 years

RESULTS AND DISCUSSION
The values show a decrease of bone density in the areas of
the femoral neck and mainly that of the greater trochanter, due
to the higher amount of cancellous bone in this area.

Fig. 7. The values of bone density measured in the study group >60
years

The results showed decrease of bone density associated withageing in the region of femoral head.

Fig. 5. The values of bone density measured in the study group <40years.

The values show a decrease of bone density in the areasof the femoral neck and mainly that of the greater trochanter,6

Fig. 8. The values of bone density in the femoral head area

Fiziologia - Physiology  2014.24.3 (83)The results showed decrease of bone density associated withageing in the region of femoral neck.

Fig. 9. The values of bone density in the femoral neck area

The results showed decrease of bone density associated withageing in the region of greater trochanter.

greater trochanter – reveal the following aspects:− bone mass is physiologically lower in the trochantericarea due to the cancellous structure of the bone in thisregion;− women aged between 40 and 60 years, therefore
more susceptible to post-menopausal osteoporosis, show adecrease of bone density in the femoral neck, but mainly in
the greater trochanter, due to the fact that this area consists
predominantly of cancellous bone which is more severely
affected by osteoporosis;− in women over 60, the loss of bone mass in the greater
trochanter is more severe due to the more advanced osteoporosis. Besides the progression of post-menopausal
osteoporosis, senile osteoporosis is an additional factor;− age-related loss of bone mass (and implicitly the
progression of post-menopausal osteoporosis) is more
severe in the greater trochanter which has a higher content
of cancellous bone.
Consequently, ageing leads to a higher incidence oftrochanteric fractures vs. femoral neck fractures. A female
patient suffering from a trochanteric fracture is older and has
a more severe osteoporosis than a female patient sufferingfrom a femoral neck fracture. The anatomic characteristicsof this region - the fermoal proximal epiphysis - and theamount of cancellous bone which is more severely affectedby osteoporosis, are essential predisposing factors of thetwo major post-traumatic pathological entities in this area:
femoral neck fractures and greater trochanteric fractures.

Fig. 10. The values of bone density in the area of the greater trochanter

The results of the investigations showed a decrease of bonedensity of the femoral proximal epiphysis associated with ageing.

Fig. 11. Average bone density in the femoral proximal epiphysi

CONCLUSIONS
Measurements of the bone density in the three areas of thefemoral proximal epiphysis – femoral head, femoral neck and2014.24.3 (83)  Fiziologia - Physiology

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rates of fracture of the hip in the United States. Geographic, sex andage variations. J. Bone Joint Surg., 1995; 77A: 695.
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FIZIOPATOLOGIA OSTEOPOROZEI – FACTORI PREDISPOZANŢI ÎN
FRACTURILE EPIFIZEI PROXIMALE A FEMURULUIREZUMATS-a efectuat un studiu anatomo-clinic cuprinzând măsurarea densităţii osoase la nivelul capului femural, colului femural şi regiunii
masivului trohanterian, pe trei grupe de vârstă ale pacientelor. Odată cu înaintarea în vârstă stocul osos s-a deteriorat, iar susceptibilitatea unui anumit focar de fractură a afectat diferit zonele de fractură studiate.
Obiectivul studiului a fost de a determina măsura în care scăderea calității substanței osoase se corelează cu vârsta și implicit
osteoporoza, porțiunile epifizei proximale a femurului mai susceptibile la pierderea de stoc osos.
Epifiza superioară a femurului a fost împărțită în trei porțiuni: cap femural, col femural, masiv trohanterian. Cercetarea s-a efectuat
prin măsurarea densității osoase de la nivelul epifizei proximale (superioare) a femurului, realizată prin examinarea computer-tomografică (CT nativ de bazin) a celor trei loturi de paciente și exprimată în Unități Hounsfield (HU).
Odată cu înaintarea în vârstă, creşte probabilitatea unei fracturi la nivelul regiunii trohanteriene în dauna uneia a colului femural.
Pacienta cu fractură a masivului trohanterian este mai în vârstă şi mai osteoporotică decât cea cu fractură a colului femural. Particularităţile anatomice ale acestei regiuni – epifiza proximală a femurului şi proporţia de ţesut osos spongios mai susceptibilă laosteoporoză, vor deveni factori favorizanţi esenţiali în cele două mari entităţi patologice post-traumatice de la acest nivel: fracturile
colului femural, respectiv fracturile masivului trohanterian.
Cuvinte cheie: cap femural, col femural, masiv traohanterian, osteoporoză

8

Fiziologia - Physiology  2014.24.3 (83)A REVIEW ON THE INFLUENCE OF MALOCCLUSION ON THE
QUALITY OF LIFEMIHAELA RAESCU1, DAN GABRIEL LAMBESCU*2, CRISTINA NUCA3, CRISTIAN FUNIERU4,DANIELA JUMANCA5
1
Department of Oral Health, “Titu Maiorescu” University, Faculty of Dental Medicine, Bucharest
2
Department of Oral Health and Community Dentistry, University of Medicine and Pharmacy “Carol Davila”, Bucharest
3
Department of Department of Preventive Dentistry, “Ovidius” University, Faculty of Dental Medicine, Constanta
4
Department of Preventive Dentistry, University of Medicine and Pharmacy “Carol Davila”, Bucharest
5
Department of Preventive, Community Dentistry and Oral Health, University of Medicine and Pharmacy “Victor Babes” Timisoara

ABSTRACTClinical significance of the oral heath related quality of life is that dentists treat not oral disease but a human being who have different
motivations and needs not only from the functionally point of view but also psychological. This concept aims to satisfy the treatment
need not only normative but also experienced, therefore, the contemporary goal of the dental treatment plan is to develop a patientcentered plan, adapted to his oral heath perception and motivation. Malocclusions are met nowadays with high frequency and thisalters not only the functions of oral cavity but also the level self-esteem and the social interactions, all of these influencing the qualityof life. Addressability to oral health services in order to correct the malocclusion is high and not only among children and teenagers,
but also among adults. Depending on the severity of the malocclusion, clinicians can assess the orthodontic treatment need and, in
addition, in countries where orthodontic treatment is offered through dental insurance, is a priority. For a successful approach of theorthodontic treatment plan, clinicians should set properly the orthodontic treatment need using appropriate instruments and adapt
the treatment plan to each patient’s psychological profile and demands and also demographic, educational and economic features.
Keywords: oral health, quality of life, malocclusion

INTRODUCTION
Quality of life is affected by any type of disease but oral diseases jeopardize not only the functional aspects but also thepsychological and social aspects (1). As long as daily activities
are altered because of the diseases in people’s lives, researchhas been and will be done in order to prevent, minimize andcorrect their effects (1, 10).
World Health Organization defines quality of life as “individuals’
perception of their position in life in the context of the culture andvalue systems in which they live and in relation to their goals,
expectations, standards and concerns”. The concept is multidimensional and it is influenced not only by the physical healthbut also by the psychological state, level of independence, social
relationship, personal beliefs and their relationship to salientfeatures of their environment (17).
Particularly, there is also the concept of oral heath related
quality of life which is, as well, multidimensional. Although, there
hasn’t been developed a definition of it, a report of the UnitedStated Surgeon General regarding oral health, provided a simple
formulation: people’s comfort when eating, sleeping and engaging in social interaction; self-esteem; and their satisfaction withrespect to their oral health” (14).
Clinical significance of the oral heath related quality of life isthat dentists treat not oral disease but a human being who havedifferent motivations and needs not only from the functionallypoint of view but also psychological and concerns such as oral
hygiene, dental check-ups and engaging in an dental insurance
plan and paying the dental treatments might influence and also
be influenced by the oral health related quality of life (1).
This concept, which aims to satisfy the treatment need not only
normative but also experienced, started to develop in industrialized, well developed countries, where people were concerned
about dental treatments not only to maintain the physical, functional heath, but also for esthetic and self-esteem (14).
Thus, if the traditional goal of dental plan was the clinicalachievement, the contemporary goal is to develop a patientcentered dental treatment plan, adapted to patient’s oral heath
perception and motivation (10).
ORAL HEALTH
Malocclusions are met nowadays with high frequency andthis alter not only the functions of oral cavity but also the levelself-esteem and the social interactions, all of these influencing
the quality of life (10).
Addressability to oral health services in order to correct themalocclusion is high and not only among children and teenagers,
but also among adults (11). Depending on the severity of themalocclusion, clinicians can assess the orthodontic treatment

Received 15th of July 2014. Accepted 9th of August 2014. Address for correspondence: Dan Gabriel Lambescu, Department of Oral Health and Community Dentistry,
Faculty of Dental Medicine - University of Medicine and Pharmacy “Carol Davila” Bucharest, Eforie Street no.4-6, postal code 50037; tel. 0040-021.314.77.10; email:lambescudan@yahoo.com

2014.24.3 (83)  Fiziologia - Physiology

9need and, in addition, in countries where orthodontic treatment
is offered through dental insurance, the priority (11).
Debates on these aspects existed due to the fact that malocclusions are considered not “disease” but “dental deviations”. These
deviations are compared to an arbitrary norm and orthodontic
treatment aims not to “cure” but to “correct the deviations”. This is
the reason why the goals of the orthodontic treatment differs fromthe most of the dental treatments (that aim the regaining of thefunctions) because some of the malocclusion are asymptomatic,with only minor functional limitations, but with significant esthetic alteration. Thus, some patients seek orthodontic treatment
mainly for the esthetic correction. In addition, patient claims andexpectations differ: There are patients to whom a malocclusionis acceptable or indifferent and there are patients that complain
about minor malocclusion (12).
To assess the severity of malocclusion, there are used different indices but these indices assess the normative treatment
need, thus, from the clinician’s perspective. This generates
some discussions when they have to deal with patients that do
not feel the treatment need although the orthodontic treatment
need index indicates so, and vice versa. This is the reason why,
nowadays, the trend in clinical practice is the approach of patientswith malocclusion from both perspectives: clinical - functional
and patient - esthetic, psychological, social (12).
To assess the impact of oral health status on quality of life,
different instruments were developed.
Taking into consideration the World Health Organization recommendations, there was first developed the Oral Heath Impact
Profile - OHIP questionnaire. This had at first 49 questions about
7 aspects in life: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social
disability and handicap (9).
More often, though, is used the short version of this questionnaire - OHIP14 which contains only 14 questions, 2 items
per domain. Answers are organized as a frequency scale with
5 choices: 0 - never, 1 - hardly ever, 2 - occasionally, 3 - fairly
often, 4 - very often/everyday. The scores varies between 0 and
56 (11, 3, 12, 10).
There are researchers that adapt or supplement this standard
questionnaire. In United Kingdom it was applied the Oral Health
Related Quality of Life - United Kingdom - OHQoL-UK that has
16 questions that refer not only to negative but only to positive
aspects in life. The multiple choice answers are formulated as ascale of severity: 1 - very bad, 2 - bad, 3 - none, 4 - good, 5 - very
good. The score varies between 16 and 80 (11).
In Brazil and Malaysia researchers applied the Oral Impacts
on Daily Performance - ODIP questionnaire, assessing theimpact of malocclusion on 9 daily activities: eating and enjoying
food, speaking and pronouncing clearly, cleaning the mouth,smiling, laughing and showing teeth without embarrassment,
maintaining emotional state without being irritable, performing
common tasks, contact with people, playing sports, sleeping (8).
Each performance is assigned two values: one for frequency ofnegative impact (0-3) and one for the severity of impact (0-3) (5).
In Saudi Arabia, Brazil, Belgium, Canada, there was used10

the Child Perception Questionnaire - CPQ. This has 37 questions referred to the impact of malocclusion on 4 aspects: oral
symptoms (6 items), functional limitation (9 items), emotional
well-being (9 items) and social well-being (13 items). In Saudi
Arabia the 13th question from the social well-being domain waseliminated because playing instrument is not a common activity
among Arabic children, so the questionnaire applied there had
36 items. Answers were organized as a scale of frequency ofthe negative experience during the last 3 months: 0 - never,1 - once-twice, 2 - sometimes, 3 - often, 4 - everyday, almost
every day. The higher the score, the more affected the qualityof life (7, 15, 8, 17).
In Belgium it was applied an additional questionnaire whichasses also the level of self-esteem: Self-Perception Profile.
This questionnaire has 35 questions about subjects’ perception
on the following aspects in life: social skills, social acceptance,
sports skills, physical appearance, behavioral manner, closefriendship and sense of dignity (8). Self-esteem is defined as
the perception of one’s own ability to master or deal effectively
with the environment and is affected by the reactions of others
toward an individual. (8).
In Canada, quality of life was assessed in relation to materialand social deprivation. Researchers used NZDep2006 Index
of Deprivation. It evaluates 9 variables referring to social andmaterial deprivation. Scores between 1 and 3 show a low level ofdeprivation. On the other hand, score between 8 and 10 showsa high level of deprivation (17).
Malocclusion is assessed using specific indices for orthodontic
treatment need. Most used index is Index of Orthodontic Treatment Need - IOTN. It has two components: IOTN-DHC - Dental
Health Component and IOTN-AC - Aesthetic Component.
IOTN-DHC - Dental Health Component evaluates 10 occlusal
traits: overjet, underjet, deep bite, open bite, crossbite, crowding, impeded eruption, defects of cleft, lip and palate and othercraniofacial anomaly, Class II and III buccal occlusions andhypodontia. Each parameter is given a value from 1 to 5 andthe higher the score, the bigger the treatment need. Scores over
3 are considered as indicating a fair treatment need based onclinical signs (9, 8, 12, 10, 11).
IOTN-AC - Aesthetic Component have scores between 1 and
10, a higher score indicating a higher treatment need. Scores
over 5 are considered as indicating a fair treatment need basedon esthetic component (9, 8, 11).
DAI - Dental Aesthetic Index measures the orthodontic treatment need on the basis of social acceptability. It assesses 10
occlusal parameters such as overjet, underjet, missing teeth,
diastema, anterior open bite, anterior crowding, anterior spacing,largest anterior irregularity (mandible and maxilla) and anteroposterior molar relationship. Each parameter is given a value
depending on the severity and then the values of all 10 items
are summed. It is added a constant value to the obtained sum
and this represents the final score. It varies between 13 and 100.
The higher the score, the higher the orthodontic treatment need.
Based on the scores, malocclusion is classified in 4 categories:
absent or minor: score 13-25, fair - score 26-31, severe - score
Fiziologia - Physiology  2014.24.3 (83)32-35 and handicap - score 36-100 (11, 4, 17, 16, 15).
ICON - Index of Complexity and Need assesses 5 components: esthetic, crowding/spacing, crossbite, open/deep bite,
buccal antero-posterior relationship. Each component is given
two values: one for the severity (from 0 to 5) and one for weight.
These two values are multiplied and then the values obtained forall 5 components are added and this represents the final score.
A higher score indicates a higher treatment need and complexity. To evaluate the ‘outcome’ component, then there must becompared the scores before and after the treatment (11, 12).
Traditionally, malocclusion is classified using the Angle systemthat take into consideration the relationship in the antero-posterior plan of the first molars. Thus, malocclusion are distributed in
3 categories: Class I - a normal molar relationship, Class II withlower molar distal than normal, while in anterior area there are
2 divisions: 1 - anterior upper teeth protruded, and 2 - anterior
upper teeth retroclined and Class III - lower molar mesial thannormal (5).
Extensive research has been done to evaluate the association
between life quality and malocclusion.
A study conducted in Belgium in 2009 on a sample of 223
children 11-16 years old, revealed that the higher the orthodontic
treatment need, the more affected life quality is (8). The mostsignificant impact of malocclusion on life quality is the socialand psychological aspect and children claim insignificantly oral
symptoms or functional limitations (8). These conclusions werealso found in another studies that took place in Brazil, one in2012 on a sample of 519 children of 11-14 years of age (15) andanother one in 2008 on 225 children, 12-15 years old (9). Also,
the same results were obtained in a study developed between
2003 and 2006 in United Kingdom when were evaluated 273
patients whose age varied between 16 and 30 years. Anotherstudy conducted in New Zealand in 2012 that assessed 783 teenagers, showed results that emphasize these conclusions (17).
Another study that confirms the conclusions above, developed in Malaysia in 2013 on a sample of 325 subjects withages between 15 and 25 years, also show that, beside that factthat patients with high normative orthodontic treatment needhave more affected quality of life, the most important impact ofmalocclusion is on the emotional state. It affects all the patients,
irrespective the severity of malocclusion, thus including thosewith minor deviations. On the other hand, patients feel they havea handicap in the presence of severe malocclusion reflected bya high orthodontic treatment need (12).
In addition, the study developed in 2008 in Brazil that includedin the sample 220 teenagers (15-16 years old) used Angle
Classification in these case for malocclusion assessment andit showed that quality of life was significantly more affected inpatients with Class III and Class II division 1 (5).
Also in Brazil, but in 2003, another study evaluated 396
18 years old men and revealed that, moreover, malocclusion
localized in maxillary anterior area affected the most the social
well-being - smiling and laughing and showing the teeth were
avoided around people. In addition, when in the anterior area
malocclusion included overjet, the impact was also on the emo2014.24.3 (83)  Fiziologia - Physiology

tional well-being and functions (there were found difficulties inbiting the food). But, in contrast to the later study, mentioned
before, life quality hasn’t been altered in patients with malocclusion localized in molar area (16).
In South Arabia, in 2013, it was developed a study that includedin the sample 278 subjects 11-14 years of age. The results foundshowed that only patients that were diagnosed with severe malocclusion, considered handicap, had the quality of life affected bymalocclusion. In these cases, all of the components of quality oflife were altered: not only the emotional state, social interaction
but also there were functional limitations oral symptoms (7).
Another study, conducted in Egypt in 2007 that evaluated 366
subjects with ages between 21 and 25 years, also confirms theimpact of malocclusion on the esthetic component of quality oflife but it confirm the results regarding the functions. In this studies, the results found state that severity of malocclusion involve
also functional limitations: pain (explained probably becauseof the temporomandibular joint alterations) and hampered
mastication (10).
Children that have a higher level of self-esteem have also ahigher quality of life. However, self-esteem does not decrease
with the increase in the severity of malocclusion (8, 4).
Women seek orthodontic treatment more frequently thanmen. Also, impact of malocclusion in quality of life is bigger inwomen that men (12, 15, 17). Other authors, however, do notagree this (7).
Impact of malocclusion on quality of life diseases with age.
Thus, teenagers are more affected than adults. It is consideredthat this can be explained by the fact that the longer people livewith malocclusion, the more they get used to it and get aware thatthe limitations in their daily activities by the malocclusion are notthat significant (12). Other authors, however, don’t agree this (7).
The higher the educational level, the bigger the impact ofmalocclusion on quality of life. This might be explained by thefact that people with a higher educational status are also concerned about the self-esteem and self-awareness (12). Yet, otherstudies show that people from family with low income have amore altered quality of life because of malocclusion (12). Other
authors concluded that the educational and economic aspects
don’t have a significant influence (9, 17).
The accuracy is better when the assessment of the association of malocclusion and quality of life is performed using, as
instruments, OHQoL-UK compared to OHIP (for quality of life
evaluation) and IOTN- DHC and ICON compared to IOTN-AC
and DAI (for malocclusion evaluation) (11).
Quality of live is significantly improved after orthodontic treatment (conclusion of a meta analysis that included 25 full-text
articles, published in 2014) (3).
CONCLUSIONS
Malocclusions alter, for certain, the quality of life. And, while thesevere malocclusion should be treated for the correction of boththe functional and psychological issues, the orthodontic treatment
for fair and even minor malocclusion aim the improvement in11the emotional and social status due to the fact that most of thepatients have these components affected. For the approach oforthodontic treatment in this manner, clinicians should set properly the orthodontic treatment need using appropriate instruments
and adapt the treatment plan to each patient’s psychological
profile and demands and also demographic, educational andeconomic features.
REFERENCES
1. Al Shamrany M. Oral health-related quality of life: a broader perspective. East Mediterr Health J. 2006;12(6):894-901.
2. Amariei C, Nucă C. Oral health and the quality of life. Oral Healthand Dental Management in the Black Sea Countries. 2006;5(4):26 -30.
3. Andiappan M, Gao W, Bernabé E, et al. Malocclusion, orthodontic
treatment, and the Oral Health Impact Profile (OHIP-14) Systematic
review and meta-analysis. Angle Orthod. 2014.
4. Agou S, Locker D, Streiner DL, et al. Impact of self-esteem on theoral-health-related quality of life of children with malocclusion. Am J
Orthod Dentofacial Orthop. 2008;134(4):484-9.
5. Bernabé E, Sheiham A, de Oliveira CM. Condition-Specific Impacts on Quality of Life Attributed to Malocclusion by Adolescents with
Normal Occlusion and Class I, II and III Malocclusion. Angle Orthod.
2008;78(6):977-82.
6. Borzabadi-Farahani A. An overview of selected orthodontic treatment needs indices, principles in contemporary orthodontics. 2011,
InTech, Available from http://www.intechopen.com/books/principlesin-contemporary-orthodontics/an-overview-of-selected-orthodontictreatment-need-indices
7. Dawoodbhoy I, Delgado-Angulo EK, Bernabé E. Impact of malocclusion on the quality of life of Saudi children. Angle Orthod.
2013;83(6):1043-8.
8. De Baets E, Lambrechts H, Lemiere J, et al. Impact of self-esteem

on the relationship between orthodontic treatment need and oral
health-related quality of life in 11- to 16-year-old children. Eur J Orthod.
2012;34(6):731-7.
9. Feu D, de Oliveira BH, de Oliveira Almeida MA, et al. Oral healthrelated quality of life and orthodontic treatment seeking. Am J Orthod
Dentofacial Orthop. 2010;138(2):152-9.
10. Hassan AH, Amin Hel-S. Association of orthodontic treatment needs
and oral health-related quality of life in young adults. Am J Orthod
Dentofacial Orthop. 2010;137(1):42-7.
11. Liu Z, McGrath C, Hägg U. Associations between orthodontic
treatment need and oral health-related quality of life among young
adults: does it depend on how you assess them? Community Dent Oral
Epidemiol. 2011;39(2):137-44.
12. Masood Y, Masood M, Zainul NN, et al. Impact of malocclusion
on oral health related quality of life in young people. Health Qual Life
Outcomes. 2013;26;11:25.
13. Nuca C, Amariei C, Rusu DL, et al. Oral Health-related quality oflife evaluation. Oral Health and Dental Management in the Black Sea
Countries. 2007;6(1):3-8.
14. Oral health in America: A report of the Surgeon General. Rockville,
Maryland, US Department of Health and Human Services, National
Institute of Dental and Craniofacial Research, National Institute of
Health, 2000:7 (NIH publication 00–4713).
15. �����������������������������������������������������������
Scapini A, Feldens CA, Ardenghi TM, et al. ����������������
Malocclusion impacts adolescents’oral health–related quality of life. Angle Orthod.
2013;83(3):512-8.
16. Traebert ES, Peres MA. Do Malocclusions Affect the Individual’s Oral
Health-Related Quality of Life? Oral Health Prev Dent. 2007;5(1):3-12.
17. ��������������������������������������������������������������
Ukra A, Foster Page LA, Thomson WM, et al. Impact�������������������
of malocclusion on quality of life among New Zealand adolescents. N Z Dent J.
2013;109(1):18-23.
18. WHOQOF Measuring quality of life. http://www.who.int/mental_health/media/68.pdf.

REVIEW ASUPRA INFLUENTEI MALOCLUZIILOR ASUPRA CALITATII VIETIIREZUMAT

Semnificatia clinica a conceptului de calitate a vietii asociata sanatatii orale este aceea ca medicii dentisti trateaza nu bolile orale, ci
o fiinta umana care are motivatii si nevoi nu numai de ordin functional ci si psihologic. Acest concept urmareste satisfacerea nu doara nevoilor de tratament normative, appreciate de medic, ci si pe cele resimtite de pacient. Astfel, actualmente medicii dentisti ar trebui
sa elaboreze planul de tratament centrat pe pacient, deci adaptat perceptiei si motivatiei acestuia asupra sanatatii orale. Malocluziile
dentare sunt intalnite actual cu o frecventa mare, iar aceasta afectiune orala are un impact nu doar asupra functionalitatii la nivelul
cavitatii bucale ci si asupra gradului de stima de sine si a interactiunii sociale, toate acestea fiind aspecte asociate calitatii vietii. Adresabilitatea catre serviciile stomatologice pentru corecrarea malocluziile este una mare, si nu doar in randul copiilor si adolescentilor,ci si in cazul adultilor. In functie de severitatea acestor malocluzii se poate stabili nevoia de tratament orthodontic, iar in tarile in caretratamentele ortodontice sunt oferite prin asigurari, se poate realiza prioritizarea corectarii malocluziilor. Pentru abordarea de succes
a planului de tratament, clinicienii trebuie sa stabileasca nevoia de tratament ortodontic pe baza unor instrumente adecvate si sa
adapteze planul de tratament in functie ce caracteristicile psihologice, dar si demografice, profesionale si economice ale pacientului.
Cuvinte cheie: sanatate orala, calitatea vietii, malocluzii

12

Fiziologia - Physiology  2014.24.3 (83)

MOTIVATIONAL CHARACTERISTICS OF ORTHODONTIC
PATIENTSDAN GABRIEL LAMBESCU 1, BOGDAN PATRICHI 2, CRISTIANA ILEANA COŞCONEL 3,
LUMINIŢA NICA4, ATENA GĂLUŞCAN5
1
Department of Oral Health and Community Dentistry, University of Medicine and Pharmacy “Carol Davila”, Bucharest
2
Department of Psychiatry and Psychology, University of Medicine and Pharmacy “Carol Davila”, Bucharest
3
Department of Modern Languages, University of Medicine and Pharmacy “Carol Davila”, Bucharest
4
Department of Odontotherapy and Endodontics, University of Medicine and Pharmacy “Victor Babes” Timişoara
5
Department of Preventive, Community Dentistry and Oral Health, University of Medicine and Pharmacy “Victor Babeş” Timişoara

ABSTRACT

Aim: Our study aimed to assess motivation factors of adherence to orthodontic treatment for children and adolescents from a private
dental office in Bucharest. Material and method: Questionnaires for identifying specific items related to motivation for orthodontic
treatment were distributed to 82 subjects aged 6-16 yrs. Results: For 83.7% of subjects the desire to straighten the teeth andimprove the smile were the most frequently reported reasons, in 36.7% cases first decision to get treatment was own volition, for63.3% it was someone else decision (38.8 % from the general dentist, 18.4% from parents and 6.1% from another known persons
who had braces). The principal perceived benefits of the orthodontic treatment were improving facial appearance (77.8%), increased
self-esteem (48.7%), and more self-reliant in social relationship (41.5%). 41.6% of subjects received negative commentaries fromcolleagues, neighborhood, and foreign people and 58.4% experienced teasing regarding their appearance in childhood. Conclusions: The results of present study emphasize the importance of assessing and understanding child patient motivation for orthodontic
treatment to assess compliance to treatment and satisfaction results obtained after treatment.
Keywords: motivation, orthodontic treatment, adolescent

INTRODUCTION
To achieve a successful orthodontic treatment and to increase
therapeutic compliance, it is important to understand the motivation of patient seeking this kind of dental treatment. The informed
consent process should clearly identify the patients’ motivations
for treatment and if these cannot be satisfied as part of thetreatment, this should be discussed in detail. By identifying apatient’s motivation for treatment, these factors can enhancepatient cooperation and compliance and reducing drop out.
Patient motivation for orthodontic therapy may be internal(when the patient perceives the treatment need and has its own
desire to appeal to treatment) or external, that appeared followingpressure from other people around them (2, 9).
From internal group factors, esthetic demands are the main
motivation factor for seeking orthodontic treatment (3). For adolescent patients, the wish for a better dental appearance is themost important, followed by dentist’s advice and by influence ofsignificant others (external factors). A study from 2009 showedthat 93.4% of the children estimated esthetic concerns as themost important reason and compared participants’ motivation
for treatment with their adherence to the treatment, these two
factors being direct correlated (1).
From esthetic motivational factors, anticipation of improved
esthetics was an important issue motivating factor (6, 7).
For adolescents, an important internal motivational factor is
exploring the sense for their own identity, hoping that improving

appearance will enhance their self confidence and self image (8).
From external motivating factors category, previous studies
conducted on adults by Kilpelainen et al (5) showed that anotherimportant factor in the motivation treatment was the recommendationof the general dentist. In addition, the detection of a malocclusion bya dentist could be an important motivational factor (10, 11). Somestudies indicated that parents are responsible for 41% of initializing
orthodontic treatment, and in a third of cases the dentist recommended orthodontic treatment (external influences). Adolescentswere not always conscious of influences from exterior and believedthat they had made self-determining decisions for treatment (4, 13).
Other external motivational factors as personal attack forpeers, teasing and the influence of mass media should be taken
into consideration, as well as internal factors (1).
Moreover, orthodontic treatment decision may be affected byadult patient’s desire to enhance its dental and facial appearance,by socio-demographic factors related to patient (gender, age,living conditions, socioeconomic level) and also by other factors
related to orthodontic treatment (time and personal values ) (12).
MATERIAL AND METHODSThe objective of this study was to identify the patients’ motives tostart and adhere to an orthodontic treatment. Participants in thispilot study were 82 orthodontic patients of a private dental officein Bucharest, aged 6-16 years old (median age 13.25 years anda standard deviation of 7.05) and gender distribution is 37% boys

Received 15th of August 2014. Accepted 10th of September 2014. Address for correspondence: Atena Găluşcan, Department of Preventive, Community Dentisty andOral Health, Faculty of Dentistry - University of Medicine and Pharmacy “Victor Babes” Timisoara, Spl.T. Vladimirescu no.14A, RO-300041, Phone: 0040-256-204950,
email: atedent@yahoo.com

2014.24.3 (83)  Fiziologia - Physiology

13and 63% girls. Prior to the study, were obtained official approval
from dental office manager and informed consent from parents.
The questionnaire for assessing motivation for orthodontic
treatment contains four questions established through semistructured interview, for identifying specific items. The questionnaire contains closed-ended questions with dichotomous andmultichotomous responses.
First question related to patient’s reasons for seeking orthodontic
treatment, the second question asked if it was the patient’s own
decision to start the treatment or external influences. The third
question assessed the subjective benefits related to this type oftreatment. The last question interrogated about previous negative
comments about appearance from peers, relatives, teachers, etc.

The results for third question (Figure 3) denoted that principal
perceived benefits of the orthodontic treatment were estimated to
be improved facial appearance (77.8%), increased self-esteem(48.7%), and more self-reliant in social relationship (41.5%). For
fourth question, results pointed out that for 41.6% of subjects
received negative commentaries from colleagues, neighborhood,and foreign people and for 58.4 having experienced teasing
regarding their appearance in childhood (Figure 4).

self-reliant in social
relationship

41.5

RESULTS
Subjects answered at first question (Figure 1) that desire
to straighten the teeth and improve the smile were the mostfrequently reported reasons (83.7% of subjects) for starting
the orthodontic treatment. The responses for second question
showed (Figure 2) that in 36.7% cases first decision to get treatment was own volition, for 63.3% it was someone else decision(38.8 % from the general dentist, 18.4% from parents and 6.1%
were influenced from another known persons who had braces).

increased selfesteem

48.7

improved facial
appearance

77.8

0

10

20

30

40

50

60

70

80

Fig. 3. Percentage of answers regarding perceived benefit of theorthodontic treatment

diminish spaces between
teeth

22.3
7.8

speech more clear
better “bite”

29.7
1

easier toothbrushing

13.4

teasing regarding
their appearance inchildhoodaligning teeth

83.7

meliorating smile

58.4

78.6
improving facial
appearance

52.4

Fig.1. Percentage of answers regarding reasons for orthodontic
treatment (%)

41.6

0

10

20

30

40

50

60

Fig. 4. Percentage of answers regarding negative commentaries

6.1

person with bracesfrom colleagues,
neighborhood, andforeign people

(%)

18.4

parents

CONCLUSIONS
38.8

dentist36.7

own volition

0

5

10

15

20

25

30

35

40

45

Fig.2. Percentage of answers regarding origin of treatment decision(%)

14

The present study demonstrate that, for children and adolescent esthetic demands, like desire to straighten the teeth andimprove the smile were the most frequently reported reasonsfor starting the orthodontic treatment, followed by improving
oral functions, as occlusion, personal hygiene procedures, andspeaking.
The majority (almost two third of subjects) had externalmotivation factors to adhere to treatment from which the dentist
represent the most important decision factor to get treatment,
Fiziologia - Physiology  2014.24.3 (83)

followed by parents and known persons under orthodontic treatment. The most commonly perceived benefits of treatment were
estimated to be esthetic outcomes, expressed by improved facial
appearance, psychological issues as increased self-esteem andsocial results, such as being more self-confident in relationships
The results of present study emphasize the importance ofassessing and understanding child patient motivation for orthodontic treatment, the compliance to treatment and satisfaction
with results obtained after treatment.
Various resources were used by the patients to gain more
information on orthodontic treatment, most discussed it with
their own dentist, thus highlighting the importance of the role of
the general dental practitioner in educating their patients about
orthodontic treatment.
REFERENCES
1. Daniels AS, Seacat JD, Inglehart MR. Orthodontic treatment
motivation and cooperation: a cross-sectional analysis of adolescentpatients’ and parents’ responses. Am J Orthod Dentofacial Orthop.
2009;136:780-7.
2. Edgerton MT Jr, Knorr NJ. Motivational patterns of patients seeking
cosmetic (esthetic) surgery. Plast Reconstr Surg. 1971;48:551-557.
3. Giddon DB. Orthodontic applications of psychological and perceptual studies of facial esthetics. Semin Orthod. 1995;1:82-93.

4. Gosney MBE. An investigation into some of the factors influencing
the desire for orthodontic treatment. Br J Orthod. 1986;13:87-94.
5. Kilpelainen PVJ, Phillips C, Tulloch JFC. Anterior tooth position andmotivation for early treatment. Angle Orthod. 1993;63:171-4.
6. Mandall NA, McCord JF, Blinkhorn AS, et al. Perceived aesthetic impact of malocclusion and oral self-perception in 14-15 year
old Asian and Caucasian children in Greater Manchester. Eur J Orthod
1999;21:175-83.
7. O’Brien KD, Kay E, Fox D, at al. Assessing oral health outcomesfor orthodontics-measuring health status and quality of life. Community
Dent Health. 1998;15:22-6.
8. Phillips C, Broder HL, Bennett ME. Dentofacial disharmony:
motivations for seeking treatment. Int J Adult Orthod Orthognath Surg.
1997;12:7-15.
9. Proffit WR, White RP. Surgical-OrthodonticTreatment. Mosby Year
Book, St Louis, 1990.
10. Sergl HG, Zentner A. Study of psychosocial aspects of adult orthodontic treatment. Int J Adult Orthod Orthognath Surg. 1997;12:17-22.
11. Shaw WC, O’Brien KD, Richmond S. Quality control in orthodontics: factors influencing the receipt of orthodontic treatment. Br Dent J.
1991;170:66-68.
12. Stenvik A, Espeland L, Linge BO, et al. Lay attitudes to dental
appearance and need for orthodontic treatment. Eur J Orthod.
1997;19:271-277.
13. Trulsson U, Strandmark M, Mohlin Bet, et al. Conformity and independence in adolescents’ motivation for orthodontic treatment. ChildDev 1968;39:1188-200.

CARACTERISTICILE MOTIVAŢIONALE ALE PACIENŢILOR CU TRATAMENT
ORTODONTICREZUMAT

Scop: Studiul urmărește evaluarea factorilor de motivație și a complianței la tratamentul ortodontic în rândul unui lot de pacienți
copii și adolescenți dintr-un cabinet privat de medicină dentară din București. Material și metodă: Pentru identificarea elementelor
specifice legate de motivația pentru tratamentul ortodontic au fost distribuite şi completate chestionare la 82 de subiecți cu vârsta
cuprinsă între 6 și 16 ani.
Rezultatele studiului arată că dorința de a-și îndrepta dinții și de a-și îmbunătăți zâmbetul au fost cele mai frecvent amintite motive(83,7% dintre subiecți), 36,7% din cazuri au apelat la tratamentul ortodontic din proprie inițiativă, pentru 63,3% dintre subiecți altcineva
a luat decizia (38.8% - medicul dentist, părinții – 18,4% și 6,1% au fost influenţaţi de alte persoane cunoscute care au purtat aparate
ortodontice). Principalele beneficii ale tratamentului ortodontic percepute de copiii și adolescenții din studiu sunt: îmbunătățirea
aspectului facial (77,8%), creșterea stimei de sine (48,7%) și îmbunătățirea relațiilor sociale (41,5%). 41,6% dintre subiecți au primit
comentarii negative din partea colegilor, vecinilor și a persoanelor necunoscute și 58,4% au fost tachinați în copilărie în legătură cu
aspectul fizionomic.
În concluzie, rezultatele studiului subliniază importanța evaluării și înțelegerii motivației pacientului copil și adolescent pentru tratamentul ortodontic în vederea stabilirii complianței la tratament și a nivelului de satisfacție în ceea ce privește rezultatele obținutedupă tratament.
Cuvinte cheie: motivație, tratament ortodontic, adolescent2014.24.3 (83)  Fiziologia - Physiology

15

TUMOR NECROSIS FACTOR EVALUATION FOR CASTING AND
SELECTIVE LASER SINTERING CO-CR ALLOYSPOP DANIEL1, LAURA CRISTINA RUSU2, COSMIN SINESCU3, MEDA LAVINIA NEGRUTIU3,ATENA GALUSCAN4, ANCA JIVANESCU1
1
University of Medicine and Pharmacy “Victor Babes” Timisoara, Faculty of Dentistry, Department of Prosthodontics
2
University of Medicine and Pharmacy “Victor Babes” Timisoara, Faculty of Dentistry, Department of Dental Materials Technology
3
University of Medicine and Pharmacy “Victor Babes” Timisoara, Faculty of Dentistry, Department of Prostheses Technology and Dental
Materials
4
University of Medicine and Pharmacy “Victor Babes” Timisoara, Faculty of Dentistry, Department of Prevention and Community Dentistry

ABSTRACT

Materials for dental applications have to meet unique requirements, including suitable mechanical properties and acceptable biocompatibility, as they are to be placed in the oral environment with a variable pH. It is known that the technological process has an
influence on the structure of the alloy, and the release of ions from dental prostheses is an indicator of the corrosion characteristics
of dental alloys. Laser sintering is a promising technology that may enable the fabrication of dental devices overcoming some of theimperfections of casting. Systemic and local cytotoxicity, allergy, and carcinogenicity result from elements in the alloy being released
into the mouth during corrosion.Tumor necrosis factor alpha (TNF-α) plays a central role in inflammation, immune system development, apoptosis, and lipid metabolism. The purpose of this paper is to evaluate the tumor necrosis factor (TNF α) corresponding toa cast and selective sintered dental Co-Cr alloys.
Key words: corrosion, laser sintered, dental alloy, tumor necrosis factor alphaINTRODUCTION
There are certain requirements towards all the materials(implants or dental appliances) which are inserted in humanbody. The following problems are considered: biological safety
tissue response, biofunctionality and corrosion resistance. The
two significant features regarding the biocompatibility are theintegrity and degradation of the material and the reaction of thehost organism (toxic effects and allergic response) (1,2).
Systemic and local cytotoxicity, allergy, and carcinogenicity all
result from elements in the alloy being released into the mouth
during corrosion. Little evidence supports concerns of castingalloys causing systemic toxicity. The occurrence of local toxic
effects (adjacent to the alloy) is not well documented, but is ahigher risk, primarily because local tissues are exposed to muchhigher concentrations of released metal ions (3). Several elements such as nickel and cobalt have relatively high potential tocause allergy, but the true risk of using alloys containing theseelements remains undefined (4-7). Prudence dictates that alloys
containing these elements be avoided if possible. Several elements in casting alloys are known mutagens, and a few suchas beryllium and cadmium are known carcinogens in different
chemical forms. Despite these facts, carcinogenic effects fromdental casting alloys have not been demonstrated.
Tumor necrosis factor alpha (TNF-α), also known as cachectinor TNFSF1A, is the prototypic ligand of the TNF superfamily. It isa pleiotropic molecule that plays a central role in inflammation,

immune system development, apoptosis, and lipid metabolism(8). TNF-α is also involved in a number of pathological conditions including asthma, Crohn’s disease, rheumatoid arthritis,
neuropathic pain, obesity, type 2 diabetes, septic shock, autoimmunity, and cancer. Human TNF-α is synthesized as a 26 kDa
type II transmembrane protein that consists of a 35 amino acid(aa) cytoplasmic domain, a 21 aatransmembrane segment, anda 177 aa extracellular domain (ECD). Within the ECD, human
TNF-α shares 97% aa sequence identity with rhesus monkey,
and 71-92% aa identity with bovine, canine, cotton rat, equine,
feline, mouse, porcine, and rat TNF-α. It is produced by a wide
variety of immune, epithelial, endothelial, and tumor cells.
TNF-α is assembled intracellular to form a no covalently linked
homotrimer which is expressed on the cell surface. Cell surface
TNF-α can both induce the lysis of tumor cells and virus infected
cells, and generate its own downstream cell signaling following
ligation by soluble TNF RI. Shedding of membrane bound TNF-α
by TACE/ADAM17 releases the bioactive cytokine, a 55 kDasoluble trimmer of the TNF-α extracellular domain.
The aim of this article is to evaluate the tumor necrosis factor(TNF α) corresponding to a cast and selective sintered dental
Co-Cr alloys.
MATERIAL AND METHODThe Quantikine Human TNF-alpha Immunoassay, which is a
3.5 or 4.5 hour solid phase ELISA designed to measure humanReceived 19th of July. Accepted 15th of August. Address for correspondence: Laura-Cristina Rusu, Department of Dental Materials Technology, Faculty of Dentistry,
University of Medicine and Pharmacy “Victor Babes” Timisoara, Eftimie Murgu Square No. 2A, RO-30041, Timisoara, Romania, phone: 0728700049, e-mail: laura.
rusu@umft.ro16

Fiziologia - Physiology  2014.24.3 (83)TNF-alpha in serum, was used for this study. This assay employs
the quantitative sandwich enzyme immunoassay technique. A
monoclonal antibody specific for TNF-α has been pre-coatedonto a micro plate. Standards and samples are pipetted into
the wells and any TNF-α present is bound by the immobilized
antibody. After washing away any unbound substances, an
enzyme-linked polyclonal antibody specific for TNF-α is added
to the wells. Following a wash to remove any unbound antibodyenzyme reagent, a substrate solution is added to the wells andcolor develops in proportion to the amount of TNF-α bound in theinitial step. The color development is stopped and the intensityof the color is measured.
The collection of the serum was perform by using the separator
tube (SST) and allows samples to clot for 30 minutes at room
temperature before centrifugation for 15 minutes at 1000 x g.
The serum was remove and the used for the study. All reagentswere brought to room temperature before use. Related to thewash buffer, if crystals have formed in the concentrate, warming
to room temperature and mixing gently until the crystals havecompletely dissolved are recommended. 20 mL of wash bufferconcentrate were dilute into deionized or distilled water to prepare
500 mL of wash buffer.
In order to obtain the substrate solution, the color reagents A
and B were mixed together in equal volumes within 15 minutesof use beingprotected from light. 200 μL of the resultant mixture
is required per well.
The TNF-α Standard were reconstituting with deionized or
distilled water. This reconstitution produces a stock solution of
10,000 pg/mL. The standards were allowed to sit for a minimumof 15 minutes with gentle agitation prior to making dilutions. 900
μL of Calibrator Diluent RD6-35 (for serum/plasma samples) were
pipetted into the 1000 pg/mL tube. 500 μL of the appropriate
Calibrator Diluent were pipetted into the remaining tubes. The
stock solution was used to produce a dilution series. Each tube
were mixed thoroughly before the next transfer. The 1000 pg/mL
standard serves as the high standard. The appropriate Calibrator
Diluent serves as the zero standards (0 pg/mL).
After the preparations of all the solution described before, theexcess microplate strips were removed from the plate frame,
return them to the foil pouch containing the desiccant pack,and reseal. 50 μL of Assay Diluent RD1F were added to eachwell. Assay Diluent RD1F will have a precipitate present. Then
200 μL of Standard solution was added per well. After that an
incubation time of 2 hours at room temperature was performed.
A plate layout is provided to record standards and samples assayed. Each well was aspirated and wash, repeating the process
three times for a total of four washes. 200 μL of TNF-α Conjugate
was added to each well. Cover with a new adhesive strip. For
serum samples an incubation of 2 hours was performed at room
temperature. The aspiration and washing procedure is repeated.
Then a 200 μL of Substrate Solution was added to each well. The
samples were incubating for 20 minutes at room temperature andprotected from light. 50 μL of Stop Solution was added to eachwell. The color in the wells was changed from blue to yellow. The
optical density of each well was determined within 30 minutes,
2014.24.3 (83)  Fiziologia - Physiology

using a microplate reader set to 450 nm.
RESULTSThe values observed for the two considered alloys were
presented in the table below:
No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

TNF alpha for Cast
Co-Cr pg/ml
9.80
8.71
7.98
11.24
7.85
9.45
9.01
9.63
9.09
9.89
9.94
9.87

TNF alpha for SLS
Co-Cr pg/ml
10.12
9.21
9.24
12.47
10.20
10.87
11.01
10.98
11.23
10.89
11.25
11.89

In Figure 1 it can be observed the difference of TNF alphaevaluation between control group and the considered cast andSLS Co-Cr alloys.

Fig. 1. The aspect of the mean results after the TNF alpha evaluation
for the considered Cast and SLS Co-Cr alloy

The values of the TNF alpha obtained from the serum wereslightly higher (between 9 and 11 pg/ml) than the normal values(2-5 pg/ml). However the increasing values are not comparablewith the inflammatory situations in which 50-60pg/ml could be
detected.
DISCUSSION
There is great concern that metal ions may impair the local
and systemic immune responses of patients with cast metallic
restorations. Therefore, interactive effects of metal ions withimmunological parameters have been investigated in vitro andin vivo. The production of various immune mediators after treat17

ment with metallic materials has been studied in lymphocyte celllines. The expression of the inflammatory mediator interleukin
2 (IL-2) and the immune effector, IgG, by T- and B-cells wasdetermined after incubation with three copper-based castingalloys. The production of both immune mediators was alteredby released cations (9). Lipopolysaccharide (LPS)-stimulated
osteoblast-like cells revealed an increased production of IL-1α
and tumor necrosis factor-α (TNF-α) after incubation with Ti, Co,
and Cr. In addition, synthesis of type I collagen was reduced (10).
Polymorphonuclear leukocytes (PMNs) are primarily involvedin the host defense against bacteria, e.g., by the production ofreactive oxygen species (ROS). Thus, the expression of ROS
was used as parameter for the determination of interactive
effects between several metal ions and PMNs. While Mo, Al,
and V enhanced ROS production, no such effect was observedwith Cr, Co, Ni, and Ti (11). Release of several cytokines fromunstimulated and stimulated peripheral blood mononuclear
cells (PBMCs) as well as cell viability and DNA synthesis were
investigated after incubation with Cr ions. This cation caused
a dose-dependent reduction of cell viability, DNA synthesis,
secretion of IL-6, and expression of soluble interleukin-2 receptor(sIL-2r). These findings suggest that chromium has the potential
to suppress the immune system (12).
Ti wear particles did not significantly alter several investigatedimmunological parameters such as peripheral blood lymphocyte activation and IL-2 secretion (13). Similar data have beenreported with murine macrophages which had been exposed
to wear debris of a Co-Cr alloy (14). But IL-1 secretion frommacrophages and bone-resorbing activity were significantly
stimulated by fine Ti particles. In contrast, the respiratory burst
and function of human PMNs were significantly inhibited by Cobase alloy particles of non-phagocytosable size (15).
The pro-inflammatory effects (IL-6 production) of numerous
metals and one noble alloy were investigated in a three-dimensional co-culture model with human fibroblasts and keratinocytes.
Increased IL-6 expression, suggestive of a pro-inflammatory
potency, was detected with Cu, Zn, Co, Ni, and Pd at low or
non-toxic concentrations (16).
Several metal ions (Ag, Au, Cu, Hg, Ni, Pd, Pt, Zn) altered thesecretion of proteins from macrophages (3). Sub-toxic concentrations of a Ni solution also induced an increase of IL-1α andTNF-α secretion from unstimulated and LPS-stimulated THP-1
monocytes (macrophages), whereas Ag and Cu enhanced IL-1α
expression only from LPS-stimulated cells (17).
Cell adhesion molecules (CAM) like E-selectin, intercellularadhesion molecule 1 (ICAM-1), etc., are important for mediatingcell-cell interactions of platelets and leukocytes with endothelial
cells. Thus, it is of great interest to determine if metal ions canalter the production of CAM by endothelial cells. Very low, subtoxic concentrations of Zn, Ni, and Co increased the expressionof E-selectin, ICAM-1, and other CAM similar to that observedwith inflammatory mediators. The authors concluded thatclinically relevant very low concentrations of these metal ions,which may be released by corrosion, might participate in thepathogenesis of tissue inflammation (18). Contrary to previous
18

experiments, ICAM-1 expression of LPS-stimulated endothelial
cells was reduced by sub-toxic Ni concentrations, but no effectwas determined in the absence of LPS. At clinically relevant, cytotoxic concentrations, Ni stimulated ICAM-1 production. These
results show that Ni might exhibit a dual action regarding ICAM-1
expression, which is modulated by microbial factors, like LPS.
Solid specimens of a Ni-containing alloy caused a significant
increase of IL-1α secretion from THP-1 monocytes, confirming
the pronounced inflammatory potency of Ni ions (4).
The significance of bacterial LPS stimulation on the inflammatory responses of various cell types following incubation withseveral metal ions is debated. After LPS stimulation, humanmonocytes/macrophages expressed significantly more cytokines
following incubation with sub-toxic concentrations of three metal
ions: IL-1α (Ti, Cr, Co), TNF-α (Ti, Cr), and IL-6 (Ti). In addition,
all cations that were used reduced the production of tumor
growth factor-α1 (TGF-α1). In the absence of LPS, however,no stimulation of monocytic cytokine expression was observed.
The effects of noble alloys and Ni-containing base metal alloys
on the levels of lymphocyte subpopulations after implantation
were investigated in vivo in a murine model (19). No alteration in
the proportion of the lymphocyte subpopulations was observed.
The concentrations of circulating T-lymphocytes and otherparameters - such as hematocrit, total and differential leukocyte
count, serum and salivary nickel concentrations, etc. - were
determined over a six-month period after patients received fixed
partial prostheses which had been made with a Ni-Cr alloy. Nochanges in salivary and serum Ni levels were found. Though
the T-lymphocyte and monocyte populations did not change, thenumber of circulating eosinophils decreased and the neutrophil
and basophil populations increased. Since basophils participate
in hypersensitivity reactions, it was concluded that hypersensitivity caused by metal ions which are released from the Ni basealloy cannot be ruled out (20). On the other hand, T-lymphocyte
proportions increased from 56% to 77% of all lymphocytes after
removal of a Ni base alloy crown in a 20-year-old patient. Thiscase report indicates that Ni may adversely influence the numberof circulating T-lymphocytes (21).
There is evidence that metallic components derived fromdental cast restorations can modulate the expression of various immunological factors and, therefore, may participate in
the etiology of various intra-oral pathological conditions. The
increased expression of cytokines after LPS stimulation ofvarious cell types indicates that bacterial toxins and materialrelated factors, cation release due to corrosion, may produce
synergistic or additive inflammatory effects in the pathogenesisof oral diseases, like oral mucositis, gingivitis/periodontitis, andalveolar bone resorption.
CONCLUSIONS
The results of our study reveal that the TNF-α related to thecasting alloys and selective laser sintered samples of Co-Cr are
similar. However more evaluation is necessary in order to drawa final conclusion.
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2. Cortizo MC, Mele MF, Cortizo AM. Metallic dental material biocompatibility in osteoblast like cells: correlation with metal ion release. Biol
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3. Wataha JC, Lockwood PE, Marek M, Ghazi M. Ability of Nicontaining biomedical alloys to activate monocytes and endothelial
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7. Misra RD, Thein-Han WW, Mali SA, Somani MC, Karjalainen LP.
Cellular activity of bioactive nanograined / ultrafine-grained materials.
Acta Biomater., 2010; 6: 2826-35.
8. Tracey KJ, Cerami A. Metabolic response to cachectin. A brief
review. Ann N Y Acad Sci., 1990; 587: 325-31.
9. Bumgardner JD, Lucas LC, Alverson MW Jr, Tilden AB. Effects ofcopper-based dental casting alloys on two lymphocyte cell lines andthe secretion of interleukin 2 and IgG. Dent Mater., 1993; 9:85-90.
10. Wang RR, Li Y. In vitro evaluation of biocompatibility of experimental titanium alloys for dental restorations. J Prosthet Dent., 1998;
80: 495-500.
11. Ciapetti G, Granchi D, Verri E, Savarino L, Cenni E, Savioli F, etal. ����������������������������������������������������������������
Fluorescent microplate assay for respiratory burst of PMNs chal-lenged in vitro with orthopedic metals. J Biomed Mater Res., 1998;
41: 455-460.
12. Granchi D, Verri E, Ciapetti G, Stea S, Savarino L, Sudanese A, etal. Bone-resorbing cytokines in serum of patients with aseptic looseningof hip prostheses. J Bone Joint Surg Br., 1998; 80: 912-7.
13. Kohilas K, Lyons M, Lofthouse R, Frondoza CG, Jinnah R, Hungerford DS. Effect of prosthetic titanium wear debris on mitogen-induced
monocyte and lymphoid activation. J Biomed Mater Res., 1999; 47:
95-103.
14. Prabhu A, Shelburne CE, Gibbons DF. Cellular proliferation andcytokine responses of murine macrophage cell line J774A.1 to polymethylmethacrylate and cobalt-chrome alloy particles. J Biomed MaterRes., 1998; 42: 655-663.
15. Shanbhag AS, Yang J, Lilien J, Black J. Decreased neutrophil
respiratory burst on exposure to cobalt-chrome alloy and polystyrene
in vitro. J Biomed Mater Res., 1992; 26: 185-195.
16. Shanbhag AS, Yang J, Lilien J, Black J. Decreased neutrophil
respiratory burst on exposure to cobalt-chrome alloy and polystyrene
in vitro. J Biomed Mater Res., 1992; 26: 185-195.
17. Wataha JC, Ratanasathien S, Hanks CT, Sun Z. In vitro IL-1β and
TNF-α release from THP-1 monocytes in response to metal ions. Dent
Mater., 1996; 12: 322-327.
18. Klein CL, Köhler H, Kirkpatrick CJ. Increased adhesion and activation of polymorphonuclear neutrophil granulocytes to endothelial cells
under heavy metal exposure in vitro. Pathobiology, 1996; 62: 90-98.
19. Zalkind M, Calderon Y, Rabinowitz R, Hadar R, Schlesinger M. The
effect of dental alloys on mouse lymphocyte subpopulations. J Oral
Rehabil., 1998; 25: 106-109.
20. Arikan A. Effects of nickel-chrome dental alloys used in dentistryon saliva and serum nickel levels, peripheral T-lymphocytes and someother blood parameters. J Oral Rehabil., 1992; 19: 343-352.
21. Eggleston DW. Effect of dental amalgam and nickel alloys on Tlymphocytes: preliminary report. J Prosthet Dent., 1994; 51: 617-623.

EVALUAREA FACTORULUI DE NECROZA TUMORALA PENTRU ALIAJELE DE
CO-CR OBTINUTE PRIN TURNARE SI SINTERIZARE LASERREZUMAT

Materialele care se utilizeaza in domeniul medicine dentare trebuie sa indeplineasca caracterisitici corespunzatoare in ceea ce priveste
proprietatile mecanice, dar si o biocompatibilitate acceptabila, ele fiind plasate in mediul bucal ce prezinta un pH variabil. Este binecunoscut ca procesul tehnologic are o influenta majora asupra structurii aliajelor ,iar eliberarea de ioni din protezele dentare este un
indicator al caracteristicilor de coroziune al acestor aliaje dentare. Procedeul tehnologic de sinterizare laser al aliajelor reprezinta otehnologie promitatoare ce permite fabricarea unor restaurari dentare ce pot contracara anumite imperfectiuni ce pot apare in procesul traditional de turnare al aliajelor. Citotoxicitatea sistemica si locala, reactiile alergice si carcinogenitatea rezulta prin eliberarea
in cavitatea bucala a anumitor elemente ca urmare a procesului de coroziune. Factorul de necroza tumorala alpha (TNF-α) joaca
un rol central in inflamatie, dezvoltarea sistemului imun, apaptoza si metabolismul lipidic. Scopul acestui studiu a fost de a evalua
comparativ factorul de necroza tumorala (TNF-α) ce corespunde unui aliaj din Co-Cr obtinut prin turnare si prin sinterizare laser.
Cuvinte cheie: coroziune, sinterizare laser, aliaj dentar, factor de necroza tumorala alpha2014.24.3 (83)  Fiziologia - Physiology

1918-FDG-PET AND PET/CT FOR MINIMAL INVASIVE DIAGNOSISOF HEAD AND NECK CANCERSILVANACANJAU1, COSMIN SINESCU2, MEDA NEGRUTIU2, LAURA RUSU2, CARMEN TODEA1
1
University of Medicine and Pharmacy ”Victor Babes”, Department of Oral Rehabilitation and Dento-periodontal Emergencies, SchoolofDentistry, 2 Eftimie Murgu Sq., 300041, Timisoara, Romania.
2
University of Medicine and Pharmacy ”Victor Babes”, Timisoara, Department of Dental Materials Technology, School of Dentistry, 2
Eftimie Murgu Sq., 300041, Timisoara, Romaia.

ABSTRACT

Aim: Our study aimed to establish the prognostic value of 18-FDG-PET by the standardized uptake values.
Materials and Methods: 18-FDG-PET is known to be useful in identifying unknown recurrent head and neck squamous cell carcinoma (HNSCC) in the post-treatment setting, second primary carcinomas or distant metastases and even primary head and necksquamous carcinoma.
Results and conclusions: PET presents a high negative predictive value for detecting recurrent HNSCC. There are some limitations
for this diagnostic instrument regarding the identification of occult nodal metastases. Also false positive readings can be generated by
the radiation effect, the muscle activity, infection and inflammation. Using new radioactive tracers, PET can be enabled in identifying
sites of hypoxia, DNA replication and protein metabolism.
Keywords: squamous carcinoma, minimal invasive diagnosis, PET/CT.

INTRODUCTION
Positron emission tomography (PET) using the radiotracer[18F]-fluoro-2-deoxy-D-glucose represents a comprehensive
imaging technique in the evaluation and staging of head and necksquamous cell carcinomas (HNSCC). A great number of malignant
tumors, including squamous carcinomas, indicate an increase in
the glucose metabolism when compared to normal tissues. A glucose analogue like 18-fluorodeoxyglucose (FDG) can be delivered
intravenously, where glucose transporters preferentially transport
it into squamous carcinomas. After undergoing phosphorylation by
hexokinase, FDG becomes trapped in the cell, making it impossible
to advance in the glycolysis pathway. Therefore PET can image
cells with preferential uptake of FDG through the positrons emitted
18
by F incorporated into the glucose analogue.
The salivary oncocytomas, thyroid Hurtle cell adenomas,
salivary Warthin’s tumors together with other benign tumors are
known to accumulate FDG. It can also be found in the brain,salivary glands, lymphoid tissue, and active muscle; therefore
FDG is not a specific marker for cancer (Figure 1).

The kidney (Figure 2) and bladder (Figure 3) can also demonstrates activity on PET scan due to the excretion of 18F. Falsepositive findings can emerge also from increase FDG uptake inareas of infection, inflammation and trauma.

Fig. 1. 18-fluorodeoxyglucose increased uptake in the brain.

Fig. 3. 18-fluorodeoxyglucose increased uptake in the bladder.

Fig.2. 18-fluorodeoxyglucose increased uptake in the kidneys.

Received 16th of August 2014. Accepted 10th of September 2014. Address for correspondence: Dr. Silvana Canjau, Department of Oral Rehabilitation and Dental
Emergencies, University of Medicine and Pharmacy ”Victor Babes”, School of Dentistry, 2 Eftimie Murgu Sq., 300041, Timisoara, Romania, phone: +40256490507,
e-mail: canjau.silvana@umft.ro.

20

Fiziologia - Physiology  2014.24.3 (83)The standard procedure for PET scan includes introducing
FDG intravenously and a waiting period for the FDG to be
distributed systemically. During this interval the patient has to
wait quietly because any muscular activity (e.g., talking) may
lead to potentially false positive interpretation due to a possible
increased FDG accumulation. Elevated serum glucose levels
reduce the sensitivity of FDG uptake into tumor tissues there forpatients who have eaten recently or with uncontrolled diabetes
shouldn’t undergo PET scanning.
FDG-PET scanning represents an important diagnosis andevaluation modality for a variety of scenarios in the HNSCC. In thismanuscript we will assess the PET utility in identifying the recurrent disease in the post-treatment, the assessment of response
following chemo-radiation therapy, the distant metastases andsecond primary tumors and the unknown primary tumor. We will
also discuss the PET limitations for detecting occult nodal disease
and the new developments in this imaging technique that may havea future impact on the HNSCC diagnosis and treatment.
MATERIALS AND METHODS
Detection of Recurrent Disease
Cancer treatment usually causes significant changes in thenormal tissues including edema and fibrosis. Conventional crosssectional imaging can be ambiguous for possible residual or recurrent disease due to scar tissue or residual soft tissue thickening,obscuring the early detection of recurrent disease (Figure 4).

Fig. 4. Comparison of conventional CT and PET scans of the same
patient. The FDG uptake in the PET image can easily indicate a possible recurrent disease.

The assessment of recurrent disease following HNSCC
therapy has been one of the most widespread applications of
FDG-PET (Figure 5).

Fig. 5. Comparison of conventional CT and PET scans of the same
patient with a history of oral squamous cell carcinoma.
2014.24.3 (83)  Fiziologia - Physiology

There are studies, which have demonstrated that PET has ahigh sensitivity for identifying recurrent carcinoma (84–100%)with moderate specificities (61 – 93%) (1-8). A review that examined 143 patients undergoing FDG-PET scans analyzed theperformance at local, regional, and distant sites (8). Due to false
positive readings PET’s specificity was lower (79%) at local sites
and higher at distant (95%) and regional (95%) sites. A SUV of
3.2 was identified as an optimal cutoff value for determining inthis study. The importance of other clinical information to theoverall PET interpretation was demonstrated by the sensitivity
and specificity of the nuclear medicine physician which wassuperior to the SUV cutoff value. Another study reported that
PET identified local recurrence in 37 of 75 patients with pharyngeal and laryngeal cancers (7). A negative FDG-PET correctly
excluded recurrent disease in 24 patients, but overlooked it in
3 patients. A positive FDG-PET scan was less reliable showing
14 false-positive findings but correctly identifying 34 cases ofrecurrence. These studies suggest that a negative PET scan isable to exclude recurrent disease (Table I).
Table I. 18-FDG-PET detection of HNSCC
Study

Patient
numberOverall
Overallsensitivity specificity

Wong et al.

143

96%

72%

Negative
predictive
value
96%

Terhaard et
al.

75

97%

82%

89%

Other studies have attempted to establish an optimal time for
the PET to be performed after the radiation therapy in order toobtain the highest accuracy. Lonneux et al. (3) showed that theaccuracy of FDG-PET was the highest (94%) when the radiation
therapy was completed more than 3 months prior to the PET
scanning. Greven et al. (9) evaluated 45 patients before andafter high- dose radiation therapy at the following intervals: 1,
4, 12, and 24 months. They discovered that PET scanning at 4
months post- radiation had a higher accuracy than at 1 month.
FDG-PET scans performed at early intervals following therapy
may lead to false results due to inflammatory effects from radiation or chemo-radiation therapy.
PET/CT for IMRT planning
Recent developments have been made for planning theintensity modulated radiation therapy (IMRT) by using PET/
CT. In a study on 28 patients with HNSCC PET/CT was used to
guide IMRT planning on. The results showed that 16 patients
presented altered tumors staging, while with CT scan basedstaging 6 patients presented higher N stages and 12 patients
presented higher T stages. Additionally with the CT the grosstarget volume (GTV) was larger in 9 cases, significantly different
when compared to PET/CT GTV, which was larger in 5 cases.
Breen demonstrated that GTV assessment in 10 patientswith HNSCC was not significantly different between PET/CT
21

and contrast CT scans, using 8 different observers. Breen also
demonstrated a higher consistency for the CT derived volumes
as compared to the PET/CT derived GTV’s. These findings
represent conflicting evidence regarding the utility of PET/CT
in comparison with conventional contrast CT when considering
GTV delineation and IMRT planning.
Distant metastases and second primary carcinomas
FDG-PET represents a great application as an initial staging
because it can provide an overview of the distant metastases,
nodal metastases, potential second primary carcinomas andeven primary tumor (Figure 6).

Fig. 6. Whole body scans – relevant for identifying distant metastasis
or second primary carcinomas.

Several small studies have assessed the potential of FDG-PET
in identifying distant metastases. When reviewing these studies,a finding on FDG-PET suggesting second primary carcinoma or
distant metastasis was assessed in 21% of patients. Following
clinical follow up or biopsy, only 27% proved to be false positivesites of disease. A limitation of these studies is rarely reported
false negative results together with the lack of controlled comparison between PET/CT and other initial staging techniques.
For patients with advanced HNSCC, using FDG-PET for
identifying distant metastases has great importance in the initialstaging. Alcohol or heavy tobacco consumption represents ahigher risk for second primary carcinomas. Further analyses arenecessary to determine the cost-effectiveness of routine FDGPET imaging related to conventional cross sectional imaging.
The unknown primary carcinoma
The correct identification of occult primary sites is highly important because the treatment can then be specifically directed andindividualized for the known site of origin, decreasing treatmentrelated morbidity. There are cases when a primary malignancy
is not identified during long-term follow-up and diagnostic evaluation even with an accurate clinical examination, conventionalcross-sectional imaging and endoscopy under anesthesia.
The use of FDG-PET in identifying unknown primary carcinomas was assessed in many small retrospective studies.
22

Unfortunately these studies present a lack of uniformity in theassessment modalities used in looking for the primary site andalso in the inclusion criteria. Rusthoven et al. (10) performed an
extensive review on 16 studies published between 1994 and2003 referring to the FDG-PET capability of identifying unknown
primary carcinomas. In all of these studies, 302 patients underwent physical examination together with CT or MRI, and mostof them underwent also pan-endoscopy. The validation of theresults was achieved by tissue biopsy, which remains the gold
standard for primary tumor diagnosis. FDG-PET identified theprimary tumor in 74 patients (24.5%). 16% of cases presented
new regional metastases while new distant metastases were detected in 11% of cases. PET accuracy was of 79% for the primarytumor identification having a sensitivity of 88% and a specificityof 75%. When evaluating the performance by anatomic site, alower specificity for tonsil malignancies and a lower sensitivity
for base of tongue malignancies were observed.
In cases with an unknown primary carcinoma discovered by
office examination, office laryngoscopy, and cross-sectional
imaging (CT or MRI) is generally recommended that patients
also undergo a PET/CT scan prior to biopsy in the operating
room (Figure 7). It could be useful for intraoperative biopsies
guiding through the sites with increased uptake on PET/CT. It
can be suggestive for the location, depth, and aggressiveness.
For up to 25% of patients, the PET/CT scan can help in establishing the correct primary site. A critical factor for the accurate
identification of the unknown primary malignancy remains theclinical expertise of the.

Fig. 7. PET/CT scan of the lungs. The patient was recommended
PET investigation after being clinically suspected of lung cancer. The
PET scan revealed no malignancies in the lungs.

Occult nodal metastases
For previously untreated patient FDG-PET was not accurate
in the detection of occult nodal disease. There are prospective
clinical trials of patients with oral malignancies in which poor accuracy by PET was proven in detecting occult nodal metastases(11-13). These lesions were identified and ultimately removed
by supraomohyoid neck dissection. In all studies sentinel lymph
Fiziologia - Physiology  2014.24.3 (83)

node mapping proved to be much more accurate than PET/CT in
identifying occult nodal metastases. In a recent prospective clinical trial, 31 patients with oral malignancies and clinically negative
necks were submitted to preoperative PET/CT investigation prior
to 36 neck dissections (14). PET/CT presented a specificity of
95% and a sensitivity of just 67%. It was considered that false
negative results were likely related either to the proximity tothe primary tumor obscuring its detection or to the presenceof microscopic metastases not detected by PET/CT. Due tothe limited sensitivity of PET/CT, it is not recommended for theidentification of occult lymph node metastases.
RESULTS AND DISCUSSIONS
The invasive common therapy for HNSCC usually results ina significant alteration of social and biologic functions (eating,breathing, speaking etc). Therefore structural integrity of thesestructures is essential for the wellbeing of the patient. In orderto preserve the functionality of these organs chemoradiotherapy(CRT) is being introduced as a definite therapy in the treatment
scheme (15-19). A disadvantage for this type of approach would
be the distortion of the anatomy in the affected area due to theradiation effects. Early detection of an occult tumor can becomechallenging in this situation therefore thorough examinations
must be carried out for these patients. The therapeutic paradigm
has shifted in these cases toward ‘‘function-preserving’’ CRT.
Therefore, a PET-based diagnostic method is desirable forpost-CRT monitoring of HNSCC.
There are some studies in the literature, which describe the
FDG-PET utility in detecting unknown primary tumors. Usually
they are limited in size and report varying results. A recent metaanalysis covered all the literature in this topic in order to guideclinical treatment by using FDG-PET (20). They investigated 589
patients and they obtained an accuracy of 81.5 with a specificity of 82.1% and a sensitivity of 80.6%. These results suggestthat 18F-FDG PET can bring important benefits to the oncologic
patients and are in accordance also with another study (21) on
302 patients that reported a sensitivity of 88.3%. The detection
rate for primary tumors is higher (33.5%) when compared with theresults in Fogarty et al. study (22.5%) (22). The 82.1% specificity
was higher than in Neider et al. review (62%) (23).
False-positive results can appear due to physiologic uptake
in the mastication muscles, lymph nodes and tonsils. FDG
accumulation can sometimes occur in patients with benign
tumors of the salivary glands (24,25), granulomatous disease or
sarcoidosis. Recent mucosal biopsies can generate tissue repair
reaction, which can increase the FDG uptake (26). There canexist other causes for false-negative results like a disruption insignal-to-noise ratio due to an increase background uptake (eg.
in the brain) (27). Kole et al. have also demonstrated that small
tumors (below FDG PET resolution) may lead to false-negative
results. The high sensitivity of FDG-PET can be associated withthe great number of true-negative results. There is a study (28)in which it is indicated that the failure to detect a primary tumor
can be attributed to immune-mediated destruction of the lesion
2014.24.3 (83)  Fiziologia - Physiology

or to spontaneous regression. The high tumor uptake having
a low background uptake in the nodal areas enables PET tobetter detect nodal disease as compared to primary HNSCC.
Lesions up to 1 cm can be detected by PET/CT if they havegood uptake of FDG (29).
An intra-observer variability in PET results can be observed
even with highly experienced nuclear medicine radiologist (30).
The identification of a primary tumor is depended on the experience of the personnel that conducts the clinical, radiologic andendoscopic examinations. Instead of indicating PET investigation
for unknown primary tumor detection in all clinical situations, itwould be recommendable to ensure that the initial diagnostic
procedure was done correctly and by experienced personnel.
False-positive results can be reduced by PET scanning in orderto obtain physiologic imaging and by CT imaging for anatomic
imaging. The CT can enhance the assessment of tumors anatomic distortion at sites with increased FDG uptake.
PET/CT compared to FDG-PET or CT was found to be superior in the detection of head and neck malignant disease (31).
In a large study (32) it was demonstrated that combined PET/CT resulted in accurate staging in 10 of the 12 patients with
CUP, whereas MRI resulted in accurate staging in 8 of these 12
patients. The anatomic data obtained using PET/ CT enhances
the accuracy of FDG-PET-directed biopsies (33).
There are studies (20,34) that confirm a percentage of approximately 60% of squamous cell carcinoma for occult primarytumors in head and neck pathology. 30% are adenocarcinomas
and the rest are tumors from the mucosa and skin, the thyroid
gland and poorly differentiated carcinoma. Usually when themetastases are from a SCC a primary tumor is found in the headand neck area. A small number of adenocarcinoma metastases
can originate in the salivary glands, nasal cavity, and the paranasal sinuses (35).
According to Ossama H et al (20) among head and neckprimary carcinomas, tumors of the tonsils (21.6%), and the baseof the tongue (13.8%), were the most prevalent. Mendenhall etal. (36) reported similar results for tumors of the tonsils that accounted for 43% and for tumors of the base of the tongue that
accounted for 39% of all primary tumors.
Prognostic Value of PET scanning
There is evidence that the standardized uptake value (SUV)
measured by FDG-PET for HNSCC may have prognostic value.
The SUV level of PET scans identifying recurrent disease wasstrongly correlated with both overall survival and relapse-free(8). Patients with SUV’s more than 6 had a 2-year relapse-freesurvival of only 10%, while patients with SUV’s less than 2 had
a 2-year relapse-free survival of 85%.
In a review on 54 patients it was demonstrated that the pretreatment SUV for patients who underwent FDG-PET prior totreatment of HNSCC was predictive of both disease-free andlocal recurrence-free survival (37). In another study on 47 patients undergoing radiation or chemo-radiation therapy for headand neck cancer, FDG-PET was performed before and up to 3
weeks after the therapy was initiated (38). PET was analyzed
23

using measurements of tumor metabolic rate (MR) and SUV
derived from blood sampling of FDG and glucose. They foundthat high MR from the post- treatment PET showed overall 5-year
survival rates of 72% and for low MR the survival rate was 35%.
Therefore, measures related to FDG metabolism obtained using
PET may have prognostic value for patients.
New Radiotracers for PET
PET represents a technique that can identify positron emission from a variety of radioactive isotopes including carbon-11,
oxygen-15, and nitrogen-13, additional to fluorine-18. Some tracers have shown high promise in selectively localizing malignant
tumors (39). A carbon-labeled amino acid (11C-methionine) canbe used as a surrogate marker for protein metabolism, having ahighly specific potential of localizing tumors. 18-Fluorothy- midline (FLT) is phosphorylated by thymidine kinase able to image
DNA synthesis. FLT is generally correlated to tumor proliferation
demonstrating encouraging early results.
Resistance to radiation therapy and tumor progression isrelated to hypoxia, which is commonly present in malignant
tumors. Hypoxic imaging with PET can be performed with 18Fmisonidazole (FMISO). It selectively accumulates in hypoxic
conditions presenting minimal uptake in sites with normal oxygenation. Early developments have suggested that FMISO canbe very useful in imaging head and neck malignancies, having
prognostic value for cases following radiation therapy (40). All
new tracers present early promise for future application, even soclinical trials and additional investigation are absolutely necessary for validating their utility in head and neck cancer diagnosis.
CONCLUSION
FDG-PET represents a highly accepted technique in evaluating HNSCC. However it cannot be considered a substitutefor careful clinical and endoscopic examination. PET/CT is anextremely useful tool for detecting recurrent HNSCC. In thesecases, PET is moderately specific but highly sensitive. Negative predictive values are high, considered reassuring for bothclinician and patient. Positive predictive values are lower due tofalse positive readings in infections, inflammations, biopsy or
post-treatment areas. An interval of 3 months or greater following completion of radiation is recommended for PET scanning.
A controversial application for PET/CT remains the intensity
modulated radiation therapy planning. In approximately 20%
of cases it can be used in identifying sites of possible second
primary carcinomas or distant metastases. PET is not recommended in the detection of occult nodal metastases. Recently
discovered radioactive tracers can be useful in identifying, on a
PET/CT scan, sites of hypoxia, protein metabolism, DNA replication, and other processes related to malignancy.
REFERENCES
1. Farber LA, Benard F, Machtay M, et al. Detection of recurrent headand neck squamous cell carcinomas after radiation therapy with 2-18F-

24

fluoro-2-deoxy-D-glucose positron emission tomography. Laryngoscope
1999; 109: 970-975.
2. Li P, Zhuang H, Mozley PD, et al. Evaluation of recurrent squamouscell carcinoma of the head and neck with FDG positron emission tomography. Clin Nucl Med 2001; 26: 131-135.
3. Lonneux M, Lawson G, Ide C, et al. Positron emission tomo- graphy
with fluorodeoxyglucose for suspected head and neck tumor recurrencein the symptomatic patient. Laryngoscope 2000; 110: 1493-7.
4. Lowe VJ, Boyd JH, Dunphy FR, et al. Surveillance for recurrent
head and neck cancer using positron emission tomography. J Clin
Oncol 2000; 18: 651-658.
5. Stokkel MP, Terhaard CH, Hordijk GJ, et al. The detection of local
recurrent head and neck cancer with fluorine-18 fluorodeox- yglucose
dual-head positron emission tomography. Eur J Nucl Med 1999; 26:
767-73.
6. Lapela M, Eigtved A, Jyrkkio S, et al. Experience in qualitative andquantitative FDG PET in follow-up of patients with suspected recurrence
from head and neck cancer. Eur J Cancer 2000; 36: 858-867.
7. Terhaard CH, Bongers V, van Rijk PP, et al. F-18-fluoro-deoxyglucose positron-emission tomography scanning in detection of local
recurrence after radiotherapy for laryngeal/pharyngeal cancer. Head
Neck 2001; 23: 933-941.
8. Wong RJ, Lin DT, Schoder H, et al. Diagnostic and prognostic
value of [(18)F] fluorodeoxyglucose positron emission tomography forrecurrent head and neck squamous cell carcinoma. J Clin Oncol 2002;
20: 4199-4208.
9. Greven KM, Williams DW III, McGuirt WF, Sr., et al. Serial positronemission tomography scans following radiation therapy of patients withhead and neck cancer. Head Neck 2001; 23: 942-946.
10. Rusthoven KE, Koshy M, Paulino AC. The role of fluorodeoxy- glucose positron emission tomography in cervical lymph node metastases
from an unknown primary tumor. Cancer 2004; 101: 2642-2649.
11. Stoeckli SJ, Steinert H, Pfaltz M, et al. Is there a role for positronemission tomography with 18F-fluorodeoxyglucose in the initial staging
of nodal negative oral and oropharyngeal squamous cell carcinoma.
Head Neck 2002; 24: 345-349.
12. Civantos FJ, Gomez C, Duque C, et al. Sentinel node biopsy in oralcavity cancer: Correlation with PET scan and immunohis- tochemistry.
Head Neck 2003; 25: 1-9.
13. Hyde NC, Prvulovich E, Newman L, et al. A new approach to pretreatment assessment of the N0 neck in oral squa- mous cell carcinoma:
The role of sentinel node biopsy and positron emission tomography.
Oral Oncol 2003; 39: 350-360.
14. Schoder H, Carlson DL, Kraus DH, et al. 18F-FDG PET/CT for
detecting nodal metastases in patients with oral cancer staged N0
by clinical examination and CT/MRI. J Nucl Med 2006; 47: 755-762.
15. Wanebo HJ, Chougule P, Akerley WL III, et al. Preoper- ative
chemoradiation coupled with aggressive resection as needed ensuresnear total control in advanced head and neck cancer. Am J Surg 1997;
174: 518-522.
16. Lefebvre J, Chevalier D, Luboinski B, et al. Long term results of the
EORTC 24891 randomized trial on larynx preservation in hypopharyngeal SCC. In: American Head and Neck Society, editors. Final programand abstract book, Sixth International Conference on Head and Neck
Cancer, Washington, DC. 2004; s001: p 212.
17. Merlano M, Vitale V, Rossi R, et al. ���������������������������
Treatment of advanced squamous cell carcinoma of the head and neck with alternating chemotherapy
and radiotherapy. N EngJ Med 1992; 327: 1115-1121.
18. Forastiere AA, Goepfert H, Maor M, et al. Concurrent chemotherapy
and radiotherapy for organ preservation in advanced laryngeal cancer.
N Eng J Med 2003; 349: 2091-2098.

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19. Lefebvre JL, Chevalier D, Luboinski B, et al. Larynx preservation in
pyriform sinus cancer: preliminary results of a European organi- zation
for research and treatment of cancer phase III trial. EORTC head andneck cooperative group. J Natl Cancer Inst 1996; 88: 899.
20. Ossama H, Tarek A.H, Medany MM. The role of FDG PET in the
diagnosis of occult primary with cervical lymph node metastases: A
meta-analysis study. Egyptian Journal of Ear, Nose, Throat and Allied
Sciences 2014; 15: 7-16.
21. Rusthoven KM, Koshy M, Paulino AC. The role of fluorodeoxy- glucose positron emission tomography in cervical lymph node metastases
from an unknown primary. Cancer 2004; 101: 2641-2649.
22. Fogarty GB, Peters LJ, Stewart J, et al. The usefulness of fluorine
18-labelled deoxy glucose positron emission tomography in the investigation of patients with cervical lymphadenopathy from an unknown
primary. Head Neck 2003; 138-145.
23. Neider C, Gregoire V, Ang K. Cervical lymph node metastases
from occult squamous cell cut down a tree to get an apple? Int J Radiat
Oncol. 2001; 50: 727-733.
24. Greven KM, Keyes JW, Williams DW, et al. Occult primary tumors
lack of benefit from positron emission tomography imaging with 2-(f18)fluoro-2-seoxy-D-glucose, vol. 86. American Cancer Society 1999;
114-118.
25. Hanasono MM, Kunda LD, Segall GM, et al. Uses and limitationsof FDG positron emission tomography in patients with head and neckcancer. Laryngoscope 1999; 109: 880-885.
26. Stokkel MPM, Terhaard CH, Hordijk GJ, et al. The detection of
unknown primary tumors in patients with cervical metastases by dualhead positron emission tomography. Oral Oncology 1999; 35: 390-394.
27. Kole AC, Nieweg OE, Prium J, et al. Detection of unknown primarytumors using positron emission tomography. American Cancer Society
1998; 82: 1160-1166.
28. Jungwhulsing M, Scheidhauer K, Damm M, et al. 2 (18) Fluoro-2deoxy-D-glucose positron emission tomography is a sensitive tool forthe detection of occult primary cancer (carcinoma of unknown primarysyndrome) with head and neck lymph node manifestation. Otolaryngol
Head Neck Surg 2000; 123: 294-301.

29. Keyes JW, Watson NE, Williams DW, et al. FDG PET in head andneck cancer. Am J Radiol 1997; 169: 1663-1669.
30. Mukherji SK, Drane WE, Mancuso AA, et al. Occult primary tumoursof the head and neck: detection with 2-[F-18] fluoro-2-deoxy glucose
SPECT. Radiology. 1996; 199: 761-766.
31. Bar-Shalom R, Yefremov N, Guralnik L, et al. Clinical perfor- manceof PET/CT in evaluation of cancer: additional value for diagnostic
imaging and patient management. J Nucl Med. 2003; 44: 1200-1209.
32. Antoch G, Vogt FM, Freudenberg LS, et al. Whole-body dualmodality PET/CT and whole-body MRI for tumor staging in oncology.
JAMA 2003; 290: 3199-3206.
33. Greven KM, Keyes JW, Williams DW, et al. Occult primary tumors
lack of benefit from positron emission tomography imaging with 2-(f-18)
fluoro-2-seoxy-D-glucose. American Cancer Society 1999; 86: 114-118.
34. Lee NK, Byers RM, Abbruzzese JL, et al. Metastatic adeno- carcinoma to the neck from an unknown primary source. Am J Surg 1991;
162: 306-309.
35. Otto PM, Otto RA. Metastatic cervical lymph nodes with occult
primary carcinomas. Curr Opin Otolaryngol Head Neck Surg 1998;
6: 102-105.
36. Mendenhall WM, Mancuso AA, Parsons JT, et al. Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes froman unknown head and neck primary site. Head Neck 1998; 20: 739-744.
37. Schwartz DL, Rajendran J, Yueh B, et al. FDG-PET prediction ofhead and neck squamous cell cancer outcomes. Arch Otolaryngol Head
Neck Surg 2004; 130: 1361-1367.
38. Brun E, Kjellen E, Tennvall J, et al. FDG
�����������������������������
PET studies during treatment: Prediction of therapy outcome in head and neck squamous cell
carcinoma. Head Neck 2002; 24: 127-135.
39. Groves AM, Win T, Haim SB, et al. Non-[18F]FDG PET in clinicaloncology. Lancet Oncol 2007; 8: 822-830.
40. Eschmann SM, Paulsen F, Reimold M, et al. Prognostic impact
of hypoxia imaging with 18F-misonidazole PET in non-small cell lungcancer and head and neck cancer before radiotherapy. J Nucl Med
2005; 46: 253-260.

DIAGNOSTIC MINIM INVAZIV AL CANCERULUI DE LA NIVELUL CAPULUISI GATULUI UTILIZAND 18-FDG-PET SI PET/CT
REZUMAT

Scop: Studiul nostru isi propune stabilirea valorii prognostice a 18-FDG-PET prin standardizarea valorilor de absorbtie.
Materiale si Metode: 18-FDG-PET este cunoscut a fii util in identificarea situatiilor necunoscute recurente de carcinom scuamos
celular de la nivelul capului si gatului (HNSCC) post-tratament, carcinomului primar secundar, metastazelor la distanta sau chiar
carcinom scuamos primar al capului si gatului.
Rezultate si concluzii: PET prezinta valoare predictiva crescut negativa pentru detectarea HNSCC recurent. Exista unele limitari
ale acestui instrument diagnostic in cea ce priveste identificarea nodulilor metastatici oculti. Dea asemenea interpretari fals positive
pot fi generate datorita efectului radiatiilor, a activitatii musculare, a infectiilor si a inflamatiilor. Utilizand noi indicatori radioactivi, se
poate facilitate identificarea prin PET a zonelor hipoxice, a replicariilor AND sau a metabolismului proteic.
Cuvinte cheie: carcinoma scuamos, diagnostic minim-invaziv, PET/CT.

2014.24.3 (83)  Fiziologia - Physiology

25

THE INCIDENCE OF OBSTRUCTIVE NASAL PATHOLOGYAMONG THE PATIENTS WITH SLEEP APNEA SYNDROME
VLAD ANDREI BUDU
IFACF – ORL “Prof. Dr. Hociota”, Bucuresti

ABSTRACT

Obstructive sleep apnea is a sleep related disorder common among middle-aged and elderly people, most of them being unaware of
their condition. Symptoms of obstructive sleep apnea include loud snoring, daytime sleepiness and personality changes. Treatments
include lifestyle changes such as losing weight (excess fat around the neck increases airway collapse) and smoking cessation.
Materials and methods: A number of 159 patients from the Institute of Phono-audiology and Functional Surgery “Prof. Dr. D. Hociota”
Bucharest were enrolled in this study between January 1st 2010 and December 31st 2013.ENT diagnosis was established performing
anterior rhinoscopy, video-endoscopy, allergic tests and CT scans.
Results: The majority of cases associated nasal deviated septum and rhinitis. Most of the patients were male smokers and the mostcommon associated pathology was arterial hypertension.
Key words: sleep apnea, deviated septum, sinusitis, polyposis

INTRODUCTION
Obstructive sleep apnea is a sleep-related breathing disorderthat is particularly common among middle-aged and elderly people.
Most of them are unaware that they have the condition and it isusually characterized by the occurrence of numerous brief (ten seconds or so) breathing interruptions during sleep. These episodes
occur when relaxation of the upper airway muscles decreases
airflow, which lowers the level of oxygen in the blood, leading tohypoxia and reoxygenation and from these to significant endocrine
and metabolic disturbance which are direct responsible for the appearance of hypertension, metabolic syndrome and cardiovascularrisk. Symptoms of obstructive sleep apnea include loud snoring,
daytime sleepiness and personality changes (4,5,8). Treatments
include lifestyle changes such as losing weight (excess fat aroundthe neck increases airway collapse) and smoking cessation (6).
Mild to moderate obstructive sleep apnea can also be treated using
a mandibular advancement device (MAD), a “splint” that fits inside
the mouth and pushes the jaw and tongue forward to increase
the space at the back of the throat and reduce airway narrowing.
For severe sleep apnea, doctors recommend continuous positive
airway pressure (CPAP), in which a machine blows pressurized
air into the airway through a facemask to keep it open.
Allergic rhinitis is a major chronic respiratory disease due toits prevalence, its impact on quality of life, performance andproductivity at work, its cost to society and its relationship toasthma. It consists of an IgE-mediated inflammation of the nasal
mucosa alone or associated with asthma (1).
Chronic rhinosinusitis (CRS) is one of the most common
chronic medical conditions, with a significant impact on patient
quality of life. CRS is broadly classified into two groups: CRS
with nasal polyposis and CRS without NP. Chronic rhinosinusitis(CRS) is a clinical syndrome characterized by mucosal inflammation of the nose and paranasal sinuses. It has been suggested
that CRS occurs as the result of an inappropriate or exaggerated
response to external environmental triggers (2,3).
It is known that patients with chronic sinusitis have reduced
sleep quality, although the underlying etiology or pathophysiology has received little attention. There are probably a multitudeof factors involved in the mechanism of sleep impairment in
CRS among them being nasal obstruction, efferent and/or afferent neural signaling, or brain-immune signaling via immune
mediators such as interleukin-1 (IL-1) and tumor necrosis factor(TNF). Accumulating evidence is elucidating the sophisticatedand intertwined communication between the central nervous
system (CNS) and the immune system (1,9).
The obstructive ENT pathology of the upper respiratory tract
has an important correlation with the obstructive sleep apnea
syndrome and the further study wants to point out this fact.
MATERIALS AND METHODS
A number of 159 patients from the Institute of Phono-audiology
and Functional Surgery “Prof. Dr. D. Hociota” Bucharest wereenrolled in this study between January 1st 2010 and December
31st 2013. In order to establish the ENT diagnosis we performed
anterior rhinoscopy, video-endoscopy, allergic tests and CT
scans. The patients were divided in groups according to gender,
hygienic and dietary factors and associated pathology. The
results were analyzed using Microsoft office excel 2010.
RESULTSOf the 159 patients in the study a total of 81% were male andReceived 14th of August 2014. Accepted 10th of September 2014. Address for correspondence: Dr. Goanta CM, Division of Physiology and Neuroscience, Universityof Medicine and Pharmacy “Carol Davila”, Bucharest, Romania, phone: +40213180762, e-mail: cristina.goanta@gmail.com

26

Fiziologia - Physiology  2014.24.3 (83)

19% were female. This is consistent with the literature data andshows a predominance of males.

Fig.1. Gender distribution

Regarding the age distribution the majority of cases (84) were
between 36-45 years old. Our data is consistent with international
literature and is highlighting an increase of the pathology in the
middle aged of population.

Fig.2. Age repartition

Hygienic-dietary factors are very important in the appearanceof the nasal obstructive syndrome. In our group a number of 115
patients were smokers and 56 worked in a polluted environment.

rior aero-digestive tract and also for the clinical diagnosis of thenasal obstructive syndrome. This way we can have a complete
diagnosis that includes nasal septum deviations, chronic rhinitis,
chronic sinusitis, polyposis or adenoiditis.
ENT examination was completed in all patients with rigid
or flexible endoscopy of the nasal region, the nasopharynx,
oropharynx, larynx and tongue base and multiple allergic tests.
Besides the ENT clinical and endoscopic examination we performed a complete clinical examination to evaluate the generalcondition and function of various organs and systems including
the liver, spleen, digestive and respiratory systems.
The main ENT pathology seen with the group of patients
studied was:
− Nasal deviated septum and chronic rhinitis (in 73
patients)− Nasal deviated septum, chronic rhinitis and chronicsinusitis - in 35 patients− Nasal deviated septum, polyposis and chronic sinusitis- in 25 patients− Allergic rhinitis - in 13 patients− Adenoiditis – in 3 patients.

Fig.4. ENT pathology

It is known that low levels of oxygen in the bloodleading to hypoxia and re-oxygenation and from these to significant endocrine
and metabolic disturbance are direct responsible for the appearance of hypertension, metabolic syndrome and cardiovascularrisk. In our group of patients 41 were known with different typesof allergies, 23 were known with arterial hypertension and 8 with
type 2 diabetes.

Fig.3. Hygienic and dietary factors

ENT clinical examination is very important for the systematicinvestigation of all areas of mucosa and submucosa of the supe2014.24.3 (83)  Fiziologia - Physiology

Fig.5. Associated pathology

27

DISCUSSION
Sleep apnea is a chapter of pathology of major importance due
to its implications of the quality of life, this patients being known
for falling asleep during day activities and lack of concentration
due to cerebral hypoxia. Several factors must be solved so thatthe patients would have a better quality of life. The main factor
is losing weight and smoking cessation. In some patients removing the upper respiratory tract obstacle can be of help. The ENT
associated pathology can be treated medical or surgical. Among
medical treatments are nasal drops, anti-inflammatory and antiallergic drugs and sometimes antibiotics.
When there are no contraindications for surgery we can perform different procedures for removing the obstacle (septoplasty,
turbinectomy, FESS, adenoidectomy) (7,8,10). Therapeuticstrategies must be based on a accurate diagnosis pointed out
by the ENT, allergist and the pulmonology specialists.
Once the diagnosis of sleep apnea has been properly
made the management of the disease requires interdisciplinary collaboration to initiate the appropriate treatment. A
nutritionist is very important to ensure an adequate nutritional
status and help the patient lose weight and maintain it. We
may also need a psychologist and the family support for thesmoking cessation.
REFERENCES
1. Kern RC, Conley DB, Walsh W, et al. Perspectives on the etiology

of chronic rhinosinusitis: An immune barrier hypothesis. Am J Rhinol,
2008; 22:549-559.
2. Fokkens WJ, Lund VJ, Mullol J, et al. European position paper onrhinosinusitis and nasal polyps. Rhinol, 2012; Suppl 23:1-298.
3. Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012: European
position paper on rhinosinusitis and nasal polyps. A summary forotorhinolaryngologists. Rhinology, 2012; 50:1-12.
4. Suratt PM, Turner BL, Wilhoit SC. Effect of intranasal obstruction
on breathing during sleep. Chest, 1986; 90: 324-329.
5. Young T, Finn L, Kim H. Nasal obstruction as a risk factor for sleepdisordered breathing. The University of Wisconsin Sleep and Respiratory
Research Group. J Allergy Clin Immunol, 1997; 99: S757-762.
6. Stradling JR, Crosby JH. Predictors and prevalence of obstructive
sleep apnoea and snoring in 1001 middle aged men. Thorax, 1991;
46: 85-90.
7. Tosun F, Kemikli K, Yetkin S, Ozgen F, Durmaz A, Gerek M. Impact
of endoscopic sinus surgery on sleep quality in patients with chronic
nasal obstruction due to nasal polyposis. J Craniofac Surg, 2009; 20:446-9.
8. Nakata S, Noda A, Yasuma F, et al. Effects of nasal surgery on sleep
quality in obstructive sleep apnea syndrome with nasal obstruction. Am
J Rhinol, 2008; 22: 59-63.
9. Lavie P, Gertner R, Zomer J, Podoshin L. Breathing disorders insleep associated with “microarousals’ in patients with allergic rhinitis. Acta Otolaryngol, 1981; 92: 529-533.
10. Li HY, Lee LA, Wang PC, Chen NH, Lin Y, Fang TJ. Nasal surgery forsnoring in patients with obstructive sleep apnea. Laryngoscope, 2008;
118: 354-359.

INCIDENTA PATOLOGIEI OBSTRUCTIVE NAZALE IN RANDUL POPULATIEICU SINDROM DE APNEE IN SOMNREZUMAT

Sindromul de apnee in somn reprezinta o tulburare comuna la pacientii de varsta medie si varstnici, majoritatea neconstientizand
patologia de care sufera. Simptomatologia include sforait, oboseala in timpul zilei si schimbari de personalitate. Tratamentul include
schimbari in stilul de viata al pacientului cum ar fi slabitul (excesul de grasime din jurul gatului ingusteaza caile aeriene) si renuntatul
la fumat. Material si metoda: Un numar de 159 de pacienti din Institutul de fono-audiologie si chirurgie functionala “Prof. Dr. D.
Hociota” Bucuresti a fost studiat intre 1 ianuarie 2010 si 31 decembrie 2013. Diagnosticul ORL a fost stabilit in urma efectuarii derinoscopii anterioare, video-fibroscopii, teste alergice, examen CT. Rezultate: Majoritatea cazurilor asociau deviatie de sept nazal si
rinita. Cei mai multi pacienti au fost de sex masculin, fumatori, si cea mai comuna patologie asociata a fost hipertensiunea arteriala.
Cuvinte cheie: sindrom de apnee in somn, deviatie sept nazal, sinuzita, polipoza

28

Fiziologia - Physiology  2014.24.3 (83)EFFECTIVENESS ASSESSMENT CRITERIA FOR CT DIAGNOSISIN MEDIASTINAL LYMPHATIC EXTENSION OF THE LUNG CANCERDANIELA CIPU, DAN SIMION CIPU
1
Department of Orthopedics-Trauma-Urology and Imagistics, University of Medicine and Pharmacy “Victor Babes” Timisoara
2
MAI County Medical Centre Timis

ABSTRACT

Lung cancer, through the characteristics of lymphatic dissemination by different areas, and in strict accordance with the cell typologyof and evolutionary stage, is one of the most common causes of mediastinal lymph nodes.
The article aims to outline the radio imaging exploration in the diagnosis of mediastinal lymphatic extension of broncho pulmonary
cancer, highlighting the clinic and morphological and anatomical interrelationships that emphasizes the importance of detection instaging and post therapeutic evaluation of the neoplastic broncho pulmonary pathology of the drained territory of the mediastinal
lymph nodes
Broncho-pulmonary neoplasm is the leading cause of cancer death throughout the world (17% of male cancers and 12% of female
cancer deaths). As a result, the medical management has been rigorously quantified in terms of clinical-histological characteristics
and the invasive tumour stage, the degree of mediastinal lymph node extension and the presence of distant metastases determinedwith the TNM staging system that is recognised globally
The x-ray examination reveals only pathological mediastinal lymph nodes that cause changes of mediastinal margins and the pleuralreflection lines.
Also if the lymph nodes are hidden behind other tumour masses existing in the mediastinum, they cannot be discovered at the x-ray
examination, which offers little information about the mediastinal structure: vessels, pericardium, pleura, and thoracic wall.
Due to the possibility to reveal all groups of pathological mediastinal lymph nodes, computed tomography is the first choice examination for the diagnosis of mediastinaladenopathies.
Besides the traditional, cytological and histopathological methods that enable the identification of pulmonary neuroendocrine carcinoma, its malignancy degree and stage, the immunohistochemical methods are very valuable for the assessment of the evolution
capacity of pulmonary neoplasia. The lung can be subjected to a large variety of complementary investigations.
Keywords: mediastinal lymphadenopathy, broncho-pulmonary neoplasm, pulmonary neuroendocrine tumours, radio-imaging
examinations

INTRODUCTION
The article aims to outline the radio imaging exploration in
the diagnosis of mediastinal lymphatic extension of broncho
pulmonary cancer, highlighting the clinic and morphological andanatomical interrelationships that emphasizes the importanceof detection in staging and post therapeutic evaluation of theneoplastic broncho pulmonary pathology of the drained territoryof the mediastinal lymph nodes.
MATERIALS AND METHODS
There were subjected to statistical analysis 134 retrospective
cases of lung cancer with mediastinal lymph extension examinedby chest CT in CT Laboratory of Military Hospital Timisoara
during January 2004-December 2006. They were investigatedclinic and biologic, bronchoscopic and histopathologic in order
to identify the diagnosis, status, appropriate therapeutic method,and in some cases post therapeutical evaluation.
Each case was analyzed from the clinical biological data,epidemiological and histopathologic bronchoscopic. They werecombined with the results of radiographic examination and CT.
It was also a review of radiographs in the images assessment,in order to detect morphological alterations of mediastinal lymph
nodes.
Radiographic examination
Radiographic examination was the first choice in all studied
cases, being performed by SIEMENS SIREGRAPH CF, in atleast two incidents: anteriorly and lesion profile, supplemented
whenever it was necessary to oblique incidence, tough-ray
radiographies or even mediastinal plane CT scans.
Diagnosis criteria
Normal mediastinal lymph nodes are not outstanding in classical radiology because they are too small or masked by the
mediastinum. With their involvement in various morbid processes
by increasing the sizes or changing the structure and consistency, mediastinal lymph nodes are visible to normal radiology,
radiological aspects determining characteristic for each lymph

Received 12th of July 2014. Accepted 10th of August 2014. Address for correspondence: Cipu Daniela, MD, Department of Orthopedics-Trauma-Urology and Imagistics, University of Medicine and Pharmacy “Victor Babes” Timisoara, Eftimie Murgu Square No. 2A, RO-300041, Timisoara, Romania, phone/fax: +40256490507,
e-mail: danscipu@yahoo.com

2014.24.3 (83)  Fiziologia - Physiology

29nodes affected group (1,2).
CT examination
CT examinations were performed using a PICKER IQ PREMIER apparatus; the sequential thoracic examining images
were obtained in multiple windows density, in order to detect
mediastinal lymph nodes morphological alterations.
Mediastinal lymph nodes location using CT examination“American Thoracic Society” Classification regarding themediastinal lymph nodes quantifies best radio anatomical the
mediastinal lymph node group’s topography. This is, therefore,
by far the most widely used in practical imaging (3). According tothis classification groups nodes are divided into two categories:
parietal and visceral (4).

II. Visceral lymphatic groups
They comprised of two groups of nodes, located to the rightside of the midline around trachea, from the entrance in thethorax to the superior border of the azygos vein arch. The
cleavage plane between the superior group (D2) and lower
group (D4) passes through the point where the brachiocephalic trunk crosses the anterior surface of trachea. Normal ishighlighted 1-3 a number of superior and 2-4 inferior ganglia.
Pathologically, are the most affected, in the inflammatory andtumor pathology.

I. Parietal lymphatic groups
Internal mammary group
It is located on the side of the sternum, posterior to the anterior
thoracic wall, along the internal mammary vessels. Normally they are
not revealed. Pathologically, they are affected by metastases frombreast carcinoma or much more rarely in a mediastinal lymphoma.
Diaphragmatic groupClassic, are described three groups:− pre-pericardic, located between xiphoid appendage
and sternum;− para-cardiac, on the lateral side of the heart, along
the phrenic nerves;− retro-crural, behind diaphragmatic insertions.
They drain lymph from the pericardium, pleura, thoracicabdominal wall and diaphragm. They are related to peritoneal
cavity and anterior segment of the liver. Efferent path links themwith the internal mammary and anterior mediastinal lymph nodes.
Normally they are not revealed. Pathologically, they are affected
in mediastinal lymphoma, metastases from breast cancer andcancer of the mediastinal pleura, and in ovarian cancer, after
metastatic involvement of peritoneum.
Posterior group
Is located paravertebral, normally not highlighted. They areinterested in lymphoma and inflammatory and neoplastic pathology of posterior mediastinum.

Fig. 2. CT sites of left paratracheal lymph nodes group. Left paratracheal group (S2, S4)

They are disposed left paratracheal, medial of the epy
aortic vessels, forming two groups, the delimitation plane
between the superior group (S2) and the inferior group(S4) is consisting of the superior border of the arc aortic.
Ganglia from the inferior left para tracheal group are different from the ones from the aortic pulmonary group by
location medially from the arterial ligament. Normally, they
are highlighted, but the number and volume are smaller than
the right group. Pathologically, are also the most common
group affected nodes.
Aortic pulmonary group (5)This is located outside the arterial ligament, occupying the
sucutaneous space between the aortic arch and the left pulmonary artery, being located to outline their external border.
Normal numbers is 2-5 and no more than 10, with a diameterof 4-8 mm. Pathologically they are affected in lymphoma andmetastasis from lung cancer.
Anterior mediastinal group (6)They are disposed retro-sternal, before the aorta, beingclassically described in three groups:− the right, in front of the superior vena cava;− transversal, in front of the left brahio-cephalic;− the left, outside of the epiaortic vessels.

Fig. 1. CT sites of right paratracheal lymph nodes group. Righ Nparatracheal group (D2, D4)30

Usually they are highlighted as 1-6 under nodes of 8 mm
diameter. Pathologically are affected in lymphoma, sarcoidosis
and bronchial cancer metastasis.
Fiziologia - Physiology  2014.24.3 (83)Fig.3. CT sites of the ganglionic groups from the aortic pulmonary
window and anterior mediastinal group.

Subcarinal group (7)They are located between the bifurcation of the trachea andthe left atrium. Usually are 1-3 nodes below 15 mm diameter.
Pathologically are affected in lung disease, lymphoma andmetastasis of bronchial cancer. Paraoesophageal group (8) iscomposed of ganglia arranged around the oesophagus. Usually
they are not highlighted; it is difficult to distinguish from the wallof the oesophagus. Pathologically are affected in metastasis ofoesophageal cancer and lung cancer located in the lower lobes
and dome

Fig.5. CT sites of bilateral tracheal bronchial groups

Intrapulmonary group (11)They are all the ganglia disposed around the bronchialbranches, inferiorly to the main bronchi. They are located athilum.
All these mediastinal lymph groups get a code number (5):− 1- supraclavicular - scaleni− 2D, 2S - para trachealis superior, right and left
− 3 - pre and retro –tracheal− 4D, 4S - paratrahealis inferior, right and left.
− 5 - aortic-pulmonary− 6 - anterior mediastinal− 7 - subcarinal− 8 - para-oesophageal− 9 - pulmonary ligament− 10D,10S - broncho tracheal, right and left
− 11D,11S - intrapulmonary, right and left
− 12 - lobar− 13 - segmentary− 14 - diaphragmatic
CT positive diagnosis criteria

Fig.4. CT sites of subcarinal ganglionic groups and paraoesophageal

Pulmonary ligament group (9)They comprise ganglia contained between the two pleurallayers. Usually are not highlighted. Pathologically are affected
metastases from lung cancer and lymphoma.
Right tracheobronchial group (D10)They are medially disposed by superior lobar bronchus origin,above right pulmonary artery. Normal is highlighted in number
and small volume. Pathologically, are constantly affected during
episodes of pulmonary infections.
Left traheo-bronchial group (S10)
Usually is easy to be identified. Pathologically, lymph nodes
give compression to carina and superior lobar bronchus in frontof main bronchus.
2014.24.3 (83)  Fiziologia - Physiology

Mediastinal lymphadenopathy is a structure CT detectable,
located in the mediastinum that has the following semiological characteristics: form, shape, size, density +/- calcification,
iodophilia, relationship with the interstitium (6).
I. Shape
In an axial CT section, mediastinal lymph nodes may appear
as round when the section plane is perpendicular to the longest axis of the lymph or may be oval when the section plane isparallel to it.
II. Outline
A net, regular outline of a lymph node shows an integrated capsule, an adenopathy having this nature can have a compressive
effect on adjacent structures. A diffuse irregular outline signifies
overcoming the capsule by a malignant process, revealing theexistence of infiltration of adjacent structures through: a tumouralprocess, an inflammatory process, mediastinal reaction to apathologic ganglion, being impossible the differentiation by the31computer tomography (7).
III. Sizes
Sizes are the semiotic major, determinant element ofcomputer tomographic diagnosis of metastatic mediastinal
lymph-nodes affected. It has been taken into account thetransverse diameter of the scanned lymph node, limit which
separates malignant from benign, stretching the limit ofvisibility more than 2 cm, according to the literature. Thus,
about 25-30% of nodes 1-2 cm in size is malignant, while
ganglia greater than 2 cm turn out to be malignant in 75%
of cases (8). Generally, the use of a smaller diameter as thelimit of malignancy means the greater the sensitivity of thediagnosis and less computer tomography of malignant lymph
nodes specificity (9).
According to dimensional criteria, mediastinal lymph nodegroups are divided into two categories (9):Ganglia which normally highlights to computer tomography:• Internal mammary• Diaphragmatic• Posterior• Para-oesophageal• of pulmonary ligament;
Any visible node is likely to be pathologic.
Groups nodes highlighted in normal CT scan:• para, pre and retro-tracheal• subcarinal• Aortic pulmonary• Anterior mediastinal;
Any node with transverse diameter greater than 10 mm is
considered pathological unless:• more than 7 mm for the left superior group and rightpara tracheal group;• more than 10 - 11 mm for subcarinal and righttracheo bronchial groups.
That is true, with the amendment that a normal sized ganglion may be the site of a malignancy, confirming the decisiverole of cytology and histopathology for definite affirmation ofmalignancy (10).
IV. Density
Normal or pathological lymph nodes are subdivided according to their densitometric structure into several categories (9):1. ganglia with homogeneous density between 30 and
60 UH.
2. ganglia with central hypo density may occur under
the following conditions:• normally, due to adipose central involution, where
the density equals mediastinal loose tissue;• in tuberculosis, due to caseous necrosis, when thedensity is slightly superior to fluid;• in lymphoma, after radio and chemo therapy due tonecrosis.
32

V. The presence or absence of calcification
They can occur at the lympho-ganglionic level in the following conditions (11):• after a non specific infection or radiotherapy;• in tuberculosis when fully calcified ganglion may
produce artefacts that appears to scan;• marginal calcifications occur in silicosis;• in sarcoidosis, the lymph node appears calcified in‘eggshell’.
CT scanning detects mainly the existence of small calcifications, proving most often a benign etiologic, but they do not
exclude malignancy when parenchyma component prevails(9).
VI. Iodophilia
Normally the lymph node density increases slightly afteradministration of contrast agent, attesting a slightly iodophilia.
Depending on contrast dose, lymph nodes may present thefollowing aspects:• central hypo density with marginal hyper dense ring,found it in normal cases, in tuberculosis, in post radio
and chemo-therapy lymphoma, as well in metastases oftesticular cancer or bronchial adenocarcinoma;• important hyper density, after contrast agent administration, certifying the existence of an inflammatory or
tumoural hyper vascularisation, being found in: Castleman’s disease; angioimmunoblastic lymphadenopathy;
metastases from: melanoma, hipernefroma, thyroid
cancer, sarcoma, carcinoid tumour.
VII. Relationship with interstitium
New semiotic element, based on radio-anatomic appearanceof hylum lymph nodes, in relation to the bronchi and vessels atinterstitial site, their exploration is detected by spiral CT examination. Normal hylum lymph nodes located in the interstitial space
between the bronchi and pulmonary vessels, often difficult todifferentiate from it, causes some straight or concave bordersof the interstitial space to the lung parenchyma. The interstitiumcontaining metastatic ganglia has convex borders toward the inflammatory reaction caused by carcinomatous lymphangitis (12).
CT diagnosis of extension
Mediastinal lymphatic extension of the broncho alveolar
cancer benefits of CT scanning both the semiotic elements that
may indicate the location of primary tumour and highlighting thelymph nodes whose topography and features may be criteria forresection or not, according to TNM staging (13):Ganglionar metastatic sites of the lung cancer:• N1 – lymph nodes in 10D and 10S homolateral• N2 – lymph nodes in 7
• N3 – lymph nodes in 10D and 10S controlateral,
revealing an inoperable lung cancer in stage IIIB (14).
CT exploring has been required scanning with the patientin blocked deep inspiration, using a mediastinal window widthof 300-500 UH and centre between 0-60 UH. Mediastinal
Fiziologia - Physiology  2014.24.3 (83)

lymphadenopathy when is highlighted, lead to detailed studyof its contiguous thin sections of 3 mm, rigorously semiologicalanalyzing the specific CT elements: form, shape, size, density,presence or absence of calcifications and iodophilia.
A total of 7 patients with lung cancer were hilar region spiral
CT investigated, using a SIEMENS SOMATOM PLUS 4 with
an apnea after deep inspiration technique, with sections of 3mm thickness and progression 3 mm / s of examination table,
resulting in a pitch of 1: 1. Mediastinal lymphadenopathies
diagnosis benefited by acquiring the spiral data to identify theirrelationship with the interstitium, new semiotic element, basedon radio-anatomic appearance of hylum lymph nodes, related tobronchi and vessels at interstitial level. They have been detected
the interstitium marginal characteristics toward lung parenchyma,
considering as normal hylum lymph nodes which determine
straight or concave borders and pathologic which due to an
inflammatory reaction caused by carcinomatous lymphangitis
have determined an interstitium with convex edges (12).
Table I. Mediastinal lympho-ganglionic staging of bronchopulmonary
cancer, according to N criterion from TNM classification
N Staging
N0
N1
N2
N3

Lymph ganglion extension
no lymph nodes
peri bronchial and/or hylum metastases in the sameside ganglia or direct intrapulmonary metastasis throughthe primary tumour extension
mediastinal and/or subcarinal in the same side metastases
mediastinal and/or subcarinal contra lateral metastases

RESULTS AND DISCUSSION
Diagnosis, staging and posttherapeutic imaging assessmentof mediastinal lymphatic extension of lung cancer has established lymph nodes presence in 134 cases. In 88 of the casesof lung cancer have been examined for diagnosis and staging,have been isolated lymph nodes as N1 stage quantization
established in 31 cases, 34 cases in N2 staging and N3 in 23
cases. Postoperative imaging evaluation, revealed mediastinal lymph nodes in 17 cases of resected bronchopulmonary
neoplasms, which was an important argument for associating
radio and chemotherapy.
Assessment of studied cases according to the ganglia sites
Statistical analysis of the sites of the 134 cases of lung cancer
with detected mediastinal lymph nodes shows in each studiedcase, the predominant involvement of drained lymphoganglionargroup, specific to area the morbid entity. The examinations forevaluation post radio and chemotherapy, detection of mediastinal
lymph nodes in 29 cases required continuation or restart, respectively. The large number of subcarinal lymph nodes occurring in
17% of cases studied, are due to damage to the lymphatic siteboth in right lung cancer and in the left and also for the 39% ofcases in stage N2.
2014.24.3 (83)  Fiziologia - Physiology

N staging results of the 88 cases of lung cancer
Assessment using postoperative chest CT scan, revealed mediastinal lymph nodes in 17 (13%) cases of broncho-pulmonary
resected neoplasms, which was an important argument for the
association of radio and chemotherapy. The examinations forpost radio- and chemotherapy assessment, detection of mediastinal lymph nodes in 29 (22%) cases required the continuationor their restarting, respectively.

Fig.6. N staging results of the 88 cases of lung cancer

Relationship with interstitium
Spiral CT examination performed at the hilum regions belonging to a number of 7 patients with lung cancer imaging
investigated, for staging and accurate assessment of further
therapeutic conduct, managed to identify lymph nodes CT
examination previously unknown.
New semiotic element, based on radio-anatomic appearanceof hilum lymph nodes is in relation to the bronchi and vessels atinterstitial site, detected their by spiral CT examination.
Normal hylum lymph nodes, located in the interstitial space
between the bronchi and pulmonary vessels, often difficult todifferentiate from it, causes some straight or concave sides of
the interstitial space toward the lung parenchyma.
This diagnostic exploration was based on identifying a specificrelationship of hilum interstitial lymph nodes with interstitiumin case of their neoplastic infiltration; it appeared outlined withconvex edges toward lung parenchyma due to the inflammatory
reaction caused by carcinomatous lymphangitis.
Thus, hilum lymph nodes are belonging to right 10 and groupleft10 group, respectively, led to the formation of convex edges
toward the parenchyma, highlighting this type of relationship with
the interstitial space being a full specified diagnostic criterion, inthe cases spiral CT explored.
CONCLUSIONSThe skills of diagnosis, staging, quantification and therapeutic
tracking, thoracic CT scan is the examination strictly necessary
for lung cancer mediastinal lymph nodes extension assessment.
Highlighting the interstitial relationship is a diagnosis criterion of
maximum specificity for malignant hilum lymph nodes highlighted
using the spiral CT, which has become a standard method ofinvestigation, with comparative radio imaging interferences.
33

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EVALUAREA EFICIENŢEI CRITERIILOR DE DIAGNOSTIC COMPUTERTOMOGRAFIC IN DIAGNOSTICAREA EXTENSIEI LIMFOGANGLIONAREMEDIASTINALE A CANCERULUI BRONHOPULMONARREZUMAT

Cancerul bronho-pulmonar, prin caracteristicile specifice de diseminare pe cale limfatică în funcţie de teritorializare şi în strictă
concordanţă cu tipologia celulară şi stadiul evolutiv, este una dintre cele mai frecvente cauze de adenopatii mediastinale
Lucrarea îşi propune să evidenţieze valoarea explorărilor radio-imagistice în diagnosticarea extensiei limfoganglionare mediastinale
a cancerului bronho-pulmonar, cu relevarea unor interrelaţii clinico-morfologice şi anatomice ce subliniază importanţa detectării
acestora, în stadializarea şi evaluarea postterapeutică a patologiei neoplazice bronho-pulmonare din teritoriul drenat de limfoganglionii mediastinali.
Materiale si metode: Au fost supuse analizei statistice retrospective 134 cazuri de cancer bronho-pulmonar cu extensie limfatică
mediastinală examinate prin computer tomografie toracică în Laboratorul CT al Spitalului Militar Timişoara, investigate clinico-biologic,
bronhoscopic şi histopatologic în vederea stabilirii diagnosticului, stadiului, conduitei terapeutice adecvate şi în unele cazuri pentru
evaluare postterapeutică. Fiecare caz a fost analizat pornind de la datele clinico-biologice, epidemiologice, bronhoscopice şi histopatologice din fişa de solicitare, care au fost coroborate cu rezultatele examinării radiografice şi CT, procedându-se la o reexaminare aradiogramelor din dosarele de evaluare a pacienților şi a imaginilor obţinute prin scanare, în mai multe ferestre de densitate, pentru
a decela alterările morfologice ale ganglionilor limfatici mediastinali. Rezultate: Prin abilităţile de diagnostic, stadializare, cuantificareşi urmărire terapeutică, scanarea CT toracică este examinarea strict necesară pentru evaluarea extensiei limfatice mediastinale acancerului bronho-pulmonar. Concluzii: Evidenţierea relaţiei cu interstiţiul constituie un criteriu de diagnostic de maximă specificitate pentru evidenţierea adenopatiilor hilare neoplazice prin computer tomografie spirală, aceasta devenind o metodă standard deinvestigaţie, cu interpolări comparative în radioimagistică.
Cuvinte cheie: limfadenopatie mediastinala, neoplasm bronhopulmonar, tumori pulmonare neuroendocrine, explorari radio-imagistice.

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