Original article
68Ga-PSMA-11 PET/CT in patients with occult biochemical recurrence of prostate carcinoma and negative 18F-Choline PET/CT. Preliminary assessment of its clinical use
68Ga-PSMA-11 PET/TC en la recidiva bioquímica oculta del carcinoma de próstata, con 18F-Colina PET/TC negativa. Valoración preliminar de su uso clínico
P.J. Plaza Lópeza,
, E. Puertasb, J.J. Aguilóc, M. Suarez-Piñerad, B. Domenecha, A. Mestre-Fuscod, J. Casalsb, J.R. Chicharo de Fleitase
Corresponding author
a Servicio de Medicina Nuclear, Hospital Quironsalud Barcelona, Barcelona, Spain
b Servicio de Radioterapia, Hospital Quironsalud Barcelona, Barcelona, Spain
c Servicio de Urología, Hospital Quironsalud Barcelona, Barcelona, Spain
d Servicio de Medicina Nuclear, Hospital del Mar, Barcelona, Spain
e Unidad de Imagen Molecular, CIMES-FGUMA, Málaga, Spain
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A: Diagnostic role of platelet, neutrophil to lymphocyte rate (NLR), prostate specific antigen (PSA), PSA density, Prostate Imaging-Reporting and Data System (PI-RADS) score, systemic immune-inflammation index (SII) in detecting high-grade prostate cancer (ISUP 3, 4 and 5). B: Diagnostic role of SII combinations in detecting high-grade prostate cancer.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Sonmez, T. Demirtas, S.T. Tombul, H. Akgun, A. Demirtas" "autores" => array:5 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Sonmez" ] 1 => array:2 [ "nombre" => "T." "apellidos" => "Demirtas" ] 2 => array:2 [ "nombre" => "S.T." "apellidos" => "Tombul" ] 3 => array:2 [ "nombre" => "H." "apellidos" => "Akgun" ] 4 => array:2 [ "nombre" => "A." 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The port is placed through the advanced access platform (Gelpoint) to prevent gas leakage.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Garisto, R. Bertolo, S.W. Reese, P. Bove, J. Kaouk" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Garisto" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Bertolo" ] 2 => array:2 [ "nombre" => "S.W." "apellidos" => "Reese" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Bove" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Kaouk" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578621000573?idApp=UINPBA00004N" "url" => "/21735786/0000004500000005/v1_202106020937/S2173578621000573/v1_202106020937/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "<span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET/CT in patients with occult biochemical recurrence of prostate carcinoma and negative <span class="elsevierStyleSup">18</span>F-Choline PET/CT. Preliminary assessment of its clinical use" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "353" "paginaFinal" => "358" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P.J. Plaza López, E. Puertas, J.J. Aguiló, M. Suarez-Piñera, B. Domenech, A. Mestre-Fusco, J. Casals, J.R. Chicharo de Fleitas" "autores" => array:8 [ 0 => array:4 [ "nombre" => "P.J." "apellidos" => "Plaza López" "email" => array:1 [ 0 => "pedro.plaza@quironsalud.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "Puertas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J.J." "apellidos" => "Aguiló" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Suarez-Piñera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "B." "apellidos" => "Domenech" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Mestre-Fusco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "J." "apellidos" => "Casals" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 7 => array:3 [ "nombre" => "J.R." "apellidos" => "Chicharo de Fleitas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Quironsalud Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radioterapia, Hospital Quironsalud Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Urología, Hospital Quironsalud Barcelona, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital del Mar, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidad de Imagen Molecular, CIMES-FGUMA, Málaga, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "<span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET/TC en la recidiva bioquímica oculta del carcinoma de próstata, con <span class="elsevierStyleSup">18</span>F-Colina PET/TC negativa. Valoración preliminar de su uso clínico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Prostate carcinoma is the second most frequent and the sixth leading cause of cancer mortality worldwide.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Early diagnosis of recurrences is a priority objective to reduce morbidity and mortality in these patients. Unlike most solid neoplasms, they do not usually show <span class="elsevierStyleSup">18</span>F-FDG avidity. The use of MRI and PET/CT with <span class="elsevierStyleSup">18</span>F/11C-Choline<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> is widely indicated in our country. However, numerous bibliographic references report inadequate sensitivity and specificity in early recurrence in cases of low prostate-specific antigen (PSA) values.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">New and promising PET radiopharmaceuticals such as <span class="elsevierStyleSup">18</span>F-FACBC,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">18</span>F-PSMA and <span class="elsevierStyleSup">68</span>Ga-PSMA-11<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> have been recently introduced.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Prostate-specific membrane antigen (PSMA) is a cell surface glycoprotein that is expressed in most prostate tumors, even in castration-resistant tumors, in primary and metastatic lesions as well. However, this expression is not completely specific, as it also occurs in other lesions and solid neoplasms.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In routine clinical practice we find patients with mildly elevated PSA values, indicative of biochemical recurrence which is not seen in magnetic resonance imaging (MRI), bone scintigraphy (BS) or <span class="elsevierStyleSup">18</span>F-Choline PET/CT studies. This generates a prolonged follow-up of these patients and sometimes they remain under observation for an undetermined period of time. Late detection of this recurrence leads to greater morbidity and mortality rates and/or more aggressive treatment.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The main objective of the present study is to assess whether <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET/CT can detect occult biochemical recurrence (indeterminate or negative MRI, BS and <span class="elsevierStyleSup">18</span>F-Choline PET/CT) in patients with low PSA levels.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The secondary objective is to evaluate the extent in which the results of <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET/CT may vary the therapeutic attitude of these patients.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">Retrospective observational study of diagnostic accuracy.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patient characteristics</span><p id="par0040" class="elsevierStylePara elsevierViewall">Fourteen patients were selected with a history of prostate carcinoma treated with curative intent (surgery and/or external radiotherapy), who presented biochemical recurrence with low PSA values (<3 ng/mL) in successive clinical evaluations. Biochemical recurrence was considered when there were two consecutive PSA levels above 0.2 ng/mL in prostatectomized patients or as PSA rise of 2 ng/mL above the nadir PSA after external radiotherapy. Data related to patients previously undergoing or receiving hormone therapy was not taken into account.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Imaging studies, prostate ultrasound, computed tomography (CT), BS and/or pelvic MRI were negative. The <span class="elsevierStyleSup">18</span>F-Choline PET/CT was negative or inconclusive. All patients were referred to an external center for <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET/CT. The time from <span class="elsevierStyleSup">18</span>F-Choline PET/CT to <span class="elsevierStyleSup">68</span>Ga-PSMA-11 performance was not to exceed three months.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Imaging protocols</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">F-Choline PET/CT</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-Choline was supplied by AAA. The preparation of the radiopharmaceutical, including radiochemical purity, was performed in compliance with the current regulations. Dose administered 3–4 MBq/kg bodyweight (range 240–390 MBq/kg).</p><p id="par0055" class="elsevierStylePara elsevierViewall">All studies were performed on a Siemens Biograph 6 Tomograph, 4 slice 47 planes, 3.27 mm slice thickness, 128 × 128, voxel size 1.95 × 1.95 mm. Reconstruction algorithm: filtered back projection using a 5.45 mm FWHM ramp filter.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Early images of the pelvis were acquired at five minutes post-injection (PI) pelvic CT with IV iodinated contrast (120−130 kV, 40−80 mA) followed by PET, 2 beds, 3 min per bed position, targeted to the prostate area. At 60 min PI, transmission CT (120−130 kV, 40−80 mA) and emission PET from the skull base to the proximal third of the femur were performed, with 4 min per bed position (anatomical region), and a total scanning time of between 20−30 min.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Images were reconstructed on a dedicated Siemens PET workstation (ESOF) located at the facilities of the Hospital Quirón in Barcelona. PET, CT and PET/CT fusion images were obtained in all three axes.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ga-PSMA-11 PET/CT</span><p id="par0070" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleSup">68</span>Ga-PSMA-11 radiopharmaceutical was obtained using the GalliaPharm 68 germanium/68gallium generator (Eckert & Ziegler Radiopharma GmbH) and PSMA-11 (GMP) was employed as a precursor (ABX, advanced biochemical compounds). The automated synthesis of <span class="elsevierStyleSup">68</span>Ga-PSMA-11 was performed based on the procedure described by Eder et al. with final radiochemical purity > 97% in all cases.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">As prior preparation, patients were instructed to fast for five hours to avoid artifacts caused by vowel motility and were allowed to continue with their regular medications. They were also recommended adequate hydration and not to retain urine in order to avoid artifacts generated by excessive urinary activity or false positives due to persistent ureteral activity. On the day of the examination, <span class="elsevierStyleSup">68</span>Ga-PSMA-11 was administered by intravenous injection, with dose calculated according to weight (2.2 MBq/kg). Additionally, furosemide (20 mg, IV) was injected immediately after IV administration of the radiopharmaceutical to avoid its accumulation in the bladder.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Images were obtained 60 min after radiopharmaceutical administration using a GE Discovery STE 4 PET/CT hybrid tomography system (GE HealthCare, Waukesha, WI, USA). In patients with excessive urinary activity with interference in the correct assessment of the prostate or adjacent structures, late imaging was performed approximately three hours after initial radiopharmaceutical administration. Images were corrected for attenuation and scatter using CT data. Image acquisition was performed using low-dose CT (auto mA, 120 KVp) with the patient in supine position with arms raised, followed by 3-D mode PET image acquisition (matrix size: 128 × 128 pixels), with an acquisition time of 3−4 min per bed in the initial study spanning from the top of skull to mid-thigh. In the late images, the acquisition time was 6 min per bed. Images were reconstructed using the integrated GE VUE point iterative reconstruction algorithm.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Imaging analysis</span><p id="par0085" class="elsevierStylePara elsevierViewall">Both studies were interpreted independently by two nuclear physicians (Dr. PJP, with 17 years of experience in PET and Dr. JRC, with 10 years of experience in PET).</p><p id="par0090" class="elsevierStylePara elsevierViewall">The interpretation of the images was initially qualitative visual, considering positive any <span class="elsevierStyleSup">18</span>F-Choline and/or <span class="elsevierStyleSup">68</span>Ga-PSMA deposit higher than the expected uptake for that structure and uptake greater than the surrounding tissue.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Subsequently, the presence of morphological alterations in the CT scan, and their coincidence with the deposits found in the PET scan, was analyzed.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In all patients the maximum and mean SUV (standard uptake value) of each lesion was calculated. No absolute cut-off point was used for the diagnosis of malignancy. The visual criterion was considered superior and defining with respect to the SUV value.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Assessment of results</span><p id="par0105" class="elsevierStylePara elsevierViewall">All suspicious images found on <span class="elsevierStyleSup">18</span>F-Choline PET/CT and/or <span class="elsevierStyleSup">68</span>Ga-PSMA-11 were validated by histological analysis of the lesions and/or by biochemical, imaging and clinical follow-up of the patient. It was not possible to assess all patients with all of the above follow-up methods.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The findings in any of the PET/CT studies were considered true positive if one or more of the following circumstances were present: positive biopsy (local or lymph node recurrences when possible), progression confirmation with an increase in size or uptake in subsequent check-ups by imaging studies and/or decrease of more than 50% in PSA values after the treatment performed on these lesions.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Patients who showed a lasting stabilization over time (>six months) or spontaneous normalization of PSA levels during follow-up, without the appearance of lesions in other imaging studies, were considered as true negatives.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Statistical analysis was performed, calculating the diagnostic validity of <span class="elsevierStyleSup">68</span>Ga-PSMA PET: sensitivity (S), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV). The Mann Whitney test was used to calculate the differences between PSA levels in patients with positive or negative <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET/CT results; a value of p < 0.05 was considered significant.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The Kappa Cohen index was used to calculate the interobserver agreement of <span class="elsevierStyleSup">68</span>Ga-PSMA PET visual interpretation.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0130" class="elsevierStylePara elsevierViewall">Patient characteristics and results of the <span class="elsevierStyleSup">18</span>F-Coline PET/CT and <span class="elsevierStyleSup">68</span>Ga-PSMA-11 studies are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The mean age of the patients was 71.1 years (range 61–86) with a Gleason score (range 6–10) and a mean pretreatment baseline PSA 11.66 ng/mL (range 2.9–19.03 ng/mL).</p><p id="par0140" class="elsevierStylePara elsevierViewall">Thirteen of the 14 patients were initially treated by radical prostatectomy (92.8%), in five cases with extended lymphadenectomy (35.7%) and external radiotherapy was performed after surgery (21.4%) in three cases. Only in one case the initial treatment was brachytherapy.</p><p id="par0145" class="elsevierStylePara elsevierViewall">PSA levels at initial biochemical recurrence had a mean value of 0.99 ng/mL (range 0.23–2.35). Under these values, the PET/CT study was performed with <span class="elsevierStyleSup">18</span>F-Choline, which was negative in 12 of 14 cases (85.7%) and indeterminate in two cases (14.3%).</p><p id="par0150" class="elsevierStylePara elsevierViewall">In case of negative or indeterminate <span class="elsevierStyleSup">18</span>F-Choline scan, <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET/CT was performed, with a mean PSA of 1.77 (range: 0.31–7.05). Nine of the 14 tests were positive (64.3%), four were negative (28.6%) and one was inconclusive (7.1%).</p><p id="par0155" class="elsevierStylePara elsevierViewall">The Kappa index of concordance between the results expressed by the two observers was 1; there was no difference in the interpretation of the studies between the two observers.</p><p id="par0160" class="elsevierStylePara elsevierViewall">The PSA values of the negative <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET/CT studies had a mean of 0.65 ± 0.3 (range: 0.31–1.03), lower than the mean value of the positive studies 2.39 ± 1.9 (range: 0.84–7.05), p = 0.008.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Three local recurrences, four exclusive recurrent locoregional adenopathies, one retrovesical recurrence, and in one case disease was found in the left seminal vesicle and in an ipsilateral adenopathy.</p><p id="par0170" class="elsevierStylePara elsevierViewall">No cases of supradiaphragmatic lymph node metastasis, bone metastases or lesions in other distant organs were detected.</p><p id="par0175" class="elsevierStylePara elsevierViewall">All patients with positive <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET were treated with complete androgen blockade (CAB) and external radiation therapy (ERT) except for the patient with retrovesical recurrence who was treated with CAB and surgery.</p><p id="par0180" class="elsevierStylePara elsevierViewall">All PSMA-positive PET findings with were confirmed after significant decrease (>50%) or PSA negativization after targeted therapy. There was no histological confirmation of the lesions due to their small size and/or difficult location.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Patients with negative or inconclusive <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET without imaging confirmation of recurrence followed strict clinical follow-up for at least four months after PSMA PET.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Once decreased PSA levels were confirmed, the reliability and diagnostic validity parameters were calculated. Inconclusive exams were considered negative for statistical purposes. Sensitivity was 90% and specificity was 100%. The PPV was 100% and the NPV was 80%. No false positives and only one false negative were found during the follow-up time of the patients.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0195" class="elsevierStylePara elsevierViewall">This is a retrospective observational study showing the introduction of PET <span class="elsevierStyleSup">68</span>Ga-PSMA-11 into routine clinical practice as a complementary diagnostic tool for occult biochemical recurrence of prostate carcinoma.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Current clinical algorithms in our environment include transrectal ultrasound, multiparametric MRI and bone scintigraphy as part of the initial evaluation in suspected biochemical recurrence. When these studies are negative or inconclusive, <span class="elsevierStyleSup">18</span>F-Choline PET/CT is used, significantly improving lesion detection rate<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>; however, results are not as desired.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Currently, new radiopharmaceuticals have been developed, including <span class="elsevierStyleSup">68</span>Ga-PSMA-11, which could improve the results obtained with <span class="elsevierStyleSup">18</span>F-Choline; and these have been proposed to replace it.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Our series has a limited number of cases, since <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET/CT is not currently part of routine clinical practice and is not yet available in most hospitals in our country. The decision to use this diagnostic tool was made on an individualized basis, assessing the expected risks and benefits for each patient.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Despite the limited number of cases evaluated, we observed that in most of them (nine out of 14 patients), <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET was able to locate foci of prostate cancer recurrence that had remained hidden for <span class="elsevierStyleSup">18</span>F-Choline PET and other imaging studies. This makes us evaluate our initial experience as a very positive one, and confirms the results described in the international literature.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,11,12</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">The mean PSA in patients with positive <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET was 2.39 ng/mL (range: 0.84–7.05), which shows that it is capable of detecting very low tumor volumes. This very low tumor burden is presumed to be positive in the way that targeted therapies with high effectiveness in disease control and lower side effects can be chosen.</p><p id="par0225" class="elsevierStylePara elsevierViewall">The recurrences were mostly local and subcentimetric regional lymph nodes that had gone unnoticed by other techniques. The low PSA levels could explain why no metastatic bone lesions were found in our series.</p><p id="par0230" class="elsevierStylePara elsevierViewall">Due to the small size and location of the suspicious lesions, histopathological confirmation of the lesions was not available, and this was a limitation of the study.</p><p id="par0235" class="elsevierStylePara elsevierViewall">However, after targeted treatment of the lesions described on PET, a clear decrease in PSA was observed (>50%), which seems to support the etiology of prostate tumor of the lesions.</p><p id="par0240" class="elsevierStylePara elsevierViewall">Negative PET <span class="elsevierStyleSup">68</span>Ga-PSMA-11 had very low PSA levels (mean: 0.65 ng/mL; range: 0.31–1.03). When faced with values of this magnitude, sequential evaluation could be recommended, while PSMA alone should be indicated when these values approach 1 ng/mL or in cases of very low PSA doubling values.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">None of the patients with negative <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET showed significant PSA rise in the first three months after the examination. Although the small sample size does not allow statistical conclusions to be drawn, it does seem to indicate a good negative predictive value.</p><p id="par0250" class="elsevierStylePara elsevierViewall">Inconclusive <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET was considered negative for statistical and analytical purposes of this study. During clinical follow-up, elevated PSA values were observed, thus these were considered false negatives.</p><p id="par0255" class="elsevierStylePara elsevierViewall">Diagnostic reliability and validity parameters described (S: 90% and Sp: 100%) are not definitive because the sample was very selected and small. We believe that it would be interesting to increase the number of patients in future reviews in order to increase its value.</p><p id="par0260" class="elsevierStylePara elsevierViewall">Another clear limitation of our study was the time interval between the PET/CT studies with <span class="elsevierStyleSup">18</span>F-Choline and <span class="elsevierStyleSup">68</span>Ga-PSMA-11, which led to a rise in mean PSA values in the second examination. This could not be solved within routine clinical practice and at the present time could only be effectively reduced in the context of a clinical trial.</p><p id="par0265" class="elsevierStylePara elsevierViewall">Future studies should determine whether <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET can completely replace Choline PET in occult biochemical recurrence and whether it can be useful at other times in the progression of prostate cancer, such as the initial staging test or for the planning of external radiotherapy.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusion</span><p id="par0270" class="elsevierStylePara elsevierViewall">The preliminary experience of the clinical use of <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET in our center corroborates the findings described in the international literature.</p><p id="par0275" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET appears to have a high capacity to detect occult biochemical recurrences of prostate carcinoma in patients with low PSA levels and negative Choline PET.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1519029" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1377531" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1519028" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1377532" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patient characteristics" ] 1 => array:3 [ "identificador" => "sec0020" "titulo" => "Imaging protocols" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "F-Choline PET/CT" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Ga-PSMA-11 PET/CT" ] ] ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Imaging analysis" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Assessment of results" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusion" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-09-04" "fechaAceptado" => "2021-01-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1377531" "palabras" => array:3 [ 0 => "PSMA" 1 => "PET/CT" 2 => "Prostate cancer" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1377532" "palabras" => array:3 [ 0 => "PSMA" 1 => "PET/TC" 2 => "Prostate cancer" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">To assess the clinical usefulness of 68Ga-PSMA PET/CT studies in patients with occult biochemical recurrence of prostate carcinoma, with negative or inconclusive radiologic and 18 F-Choline PET/CT imaging studies.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Retrospective descriptive study. The first 14 patients with a history of prostate carcinoma, treated with curative intent and presenting suspicion of biochemical recurrence with low PSA values (<3 ng/mL) were selected. Imaging studies, prostate ultrasound, pelvic CT and/or MRI were negative, and all of them had a negative or inconclusive 18F-Choline PET/CT.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">All patients were referred to 68 Ga-PSMA-11 PET/CT. Protocol: Dose 2.2 M Bq/kg. 20 mg furosemide at start. PET/CT images from skull base to proximal third of thighs at 60 min, and late images at 3 h if needed.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The 68 Ga-PSMA-11 PET/CT was able to localize the occult biochemical recurrence in 9 of the 14 patients (64.2%), and it affected the therapeutic attitude in all of them.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Four patients (28.5%) obtained a negative or inconclusive 68 Ga-PSMA-11 PET/CT and continued under vigilant approach with PSA controls and imaging studies according to the clinical guidelines. These patients had the lowest PSA values (less than 1 ng/mL).</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">One of the 68 Ga-PSMA-11 PET/CT studies was inconclusive, reporting the presence of a doubtful right iliac adenopathy.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">68 Ga-PSMA-11 PET/CT allows an early diagnosis, with low PSA values, of occult biochemical recurrence of prostate carcinoma, even in patients with negative 18 F-Choline PET/CT.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Valorar la utilidad de los estudios PET/TC 68Ga-PSMA en la práctica clínica de los pacientes con recidiva bioquímica oculta de carcinoma de próstata, con estudios de imagen radiológicos y PET/TC 18F-Colina negativos o no concluyentes.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo retrospectivo. Se seleccionaron los primeros 14 pacientes con antecedentes de carcinoma de próstata, tratados con intención curativa y que presentaban sospecha de recidiva bioquímica con valores bajos de PSA (<3 ng/mL). Los estudios de imagen, ecografía prostática, TC y/o RM pélvica eran negativos, y todos ellos tenían un PET/TC 18F-Colina negativo o no concluyente. Se derivó a todos los pacientes para realizarse un 68 Ga-PSMA-11PET/TC. Protocolo: Dosis 2.2 M Bq/Kg. 20 mg de furosemida en el minuto 0. Imágenes PET/TC desde calota craneal hasta tercio proximal de muslos a los 60 min, e imágenes tardías a las 3 horas si precisara.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">: En 9 de los 14 pacientes (64.2%) el 68 Ga-PSMA-11PET/TC consiguió localizar la recidiva bioquímica oculta, y en todos ellos hubo cambios en la actitud terapéutica. En 4 de los 14 pacientes (28.5%) el 68 Ga-PSMA-11PET/TC resultó negativo o no concluyente, se prosiguió con la actitud vigilante con controles de PSA y estudios de imagen según los protocolos habituales. Estos pacientes presentaban los valores más bajos de PSA (inferiores a 1 ng/mL). Uno de los estudios 68 Ga-PSMA-11PET/TC fue no concluyente, informándose la presencia de una dudosa adenopatía iliaca derecha.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">El 68 Ga-PSMA-11PET/TC permite un diagnóstico precoz, con valores bajos de PSA, de la recidiva bioquímica oculta del carcinoma de próstata, incluso en pacientes con 18F-Colina PET/TC negativos.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Plaza López PJ, Puertas E, Aguiló JJ, Suarez-Piñera M, Domenech B, Mestre-Fusco A, Casals J, Chicharo de Fleitas JR. <span class="elsevierStyleSup">68</span>Ga-PSMA-11 PET/TC en la recidiva bioquímica oculta del carcinoma de próstata, con <span class="elsevierStyleSup">18</span>F-Colina PET/TC negativa. Valoración preliminar de su uso clínico. Actas Urol Esp. 2021;45:353–358.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">DX: diagnosis; RP: Radical prostatectomy; LDN: Lymphadenectomy; ERT: External radiotherapy; BQ: Brachytherapy; Adp: Adenopathy.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Initial Gleason \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PSA at Dx \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PSA pre-<span class="elsevierStyleSup">18</span>F-Choline \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleSup">18</span>F-Choline PET/CT findings \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PSA pre-<span class="elsevierStyleSup">18</span>F-Choline \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleSup">68</span>Ga-PSMA PET/CT findings \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6,05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP + LDN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2,21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adp \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5,21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5,25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inconclusive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrovesical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19,03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP + ERT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2,35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7,05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Seminal I + Adp \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7,31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP + ERT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inconclusive \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP + ERT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2,19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adp \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4,5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP + LDN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adp \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adp \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5,3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inconclusive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3,26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7,87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP + LDN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4,98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14,4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP + LDN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2,38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2,9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RP + LDN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2608382.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics and <span class="elsevierStyleSup">18</span>F-Choline PET/CT and <span class="elsevierStyleSup">68</span>Ga-PSMA-11 results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global cancer statistics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. 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