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Original article
The effect of diagnosis delay in testis cancer on tumor size, tumor stage and tumor markers
Efecto del retraso en el diagnóstico del cáncer testicular en el tamaño tumoral, estadio y marcadores tumorales
O. Gerceka,
Corresponding author
osmangercek1989@hotmail.com

Corresponding author.
, K. Topalb, A.K. Yildizc, K. Ulusoya, V.M. Yazara
a Afyonkarahisar Health Sciences University, Department of Urology, Afyonkarahisar, Turkey
b Afyonkarahisar State Hospital, Department of Urology, Afyonkarahisar, Turkey
c Ankara Bilkent City Hospital, Department of Urology, Ankara, Turkey
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Testicular cancer is the most commonly diagnosed solid tumor in young men aged 20&#8211;34 years&#44; and its incidence is increasing with each passing decade&#44; especially in industrialized societies&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> In Western societies&#44; approximately 3&#8211;10 new cases are detected per 100&#44;000 men per year&#46; While it constitutes about 1&#37; of adult neoplasms&#44; it is responsible for 5&#37; of urological cancers&#46; The most common histological type is germ cell tumors &#40;GCT&#41; with a rate of 90&#8211;95&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> GCTs are divided into two main groups as seminoma and non-seminoma&#46; Non-seminomas are divided into four histological subtypes as embryonal carcinoma&#44; yolk sac tumor&#44; choriocarcinoma&#44; and teratoma&#44; but they usually appear as a mixture of these histological types&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> While seminomas are most commonly seen in the 4th decade of life&#44; non-seminoma tumors are more common in the 3rd decade&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Non-seminoma tumors have a more aggressive course than seminomas and they constitute the majority of high-stage testicular tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The risk factors known for testicular tumor development are cryptorchidism&#44; Klinefelter syndrome&#44; infertility&#44; a history of testicular tumor in a first-degree relative&#44; tumor in the contralateral testis&#44; and the presence of testicular intraepithelial neoplasia &#40;TIN&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> It has been stated that microlithiasis alone does not increase the risk of testicular cancer in patients who do not have these risk factors compared to the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The most common symptom for admission in testicular cancer cases is a painless unilateral scrotal palpable mass or testicular swelling&#46; In 20&#37; of patients&#44; the first symptom is scrotal pain&#46; In some patients&#44; abdominal and back pain may be seen and may be a sign of metastatic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The first imaging method to confirm the testicular tumor and check the other testicle is USG&#46; Its sensitivity is close to 100&#37; and it provides detailed information about the anatomical localization of the tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Contrast-enhanced thorax and abdomen computed tomography &#40;CT&#41; is recommended for all patients for staging after pathological diagnosis or before orchiectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Tumor markers are very valuable for diagnosis&#44; staging&#44; and prognosis in testicular cancer&#46; Alpha-fetoprotein &#40;AFP&#41;&#44; beta-human chorionic gonadotropin &#40;B-hCG&#41;&#44; and lactate dehydrogenase &#40;LDH&#41; are routinely used tumor markers in testicular tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> LDH is a less specific marker that can be elevated in seminoma and non-seminoma tumors but is associated with advanced disease&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> There is an increase in B-hCG or AFP in 90&#37; of non-seminoma tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Approximately 30&#37; of seminomas may have high &#946;-hCG levels at the time of diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> A recent study reported that preoperative albumin&#47;globulin ratio is an important marker in predicting lymph node involvement&#44; distant metastasis and prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In every patient diagnosed with a testicular tumor&#44; the gold standard treatment is inguinal orchiectomy at the level of the internal inguinal ring with all layers of the testis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The favorable effect of early diagnosis on survival in testicular cancer has been known for many years&#46; When testicular cancer is diagnosed at high clinical stages&#44; its prognosis worsens&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> A 5-year survival rate was found to be 99&#37; in localized testicular cancer&#44; 97&#37; in patients with regional lymph node involvement&#44; and 73&#37; in patients with distant metastasis&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The time from the onset of symptoms to the day of diagnosis has been defined as the diagnostic delay &#40;DD&#41;&#46; In 1981&#44; Bosl et al&#46; observed that the length of the DD was associated with a higher stage of cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Patients who experience delay may also require more additional treatment and morbidity rates may increase&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> As in other malignancies&#44; early recognition of symptoms and rapid admission time play an important role in the early diagnosis of testicular cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In studies investigating the causes of DD in testicular cancer&#44; it has been stated that patients thinking of testicular swelling as a temporary problem and embarrassment due to the perception of private organs delays the admission period&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this study&#44; we aimed to determine the diagnostic features of patients with testicular cancer&#44; to examine the effect of DD on tumor size&#44; tumor stage&#44; and serum tumor markers&#44; and to reveal the possible benefits of early diagnosis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material method</span><p id="par0025" class="elsevierStylePara elsevierViewall">This study was conducted in the urology clinic of Hospital of Afyonkarahisar Health Sciences University and the urology clinic of Ankara Bilkent City Hospital between April 2023 and May 2023&#46; The sample size was not calculated in the study&#44; and an attempt was made to reach the entire population&#46; After obtaining the ethical approval &#40;Afyonkarahisar Health Sciences University Clinical Research Ethics Committee&#46; 2011-KAEK-2&#44; 2023&#47;243&#41; we recorded the data retrospectively&#46; Our study was conducted in accordance with the principles of the Declaration of Helsinki&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients who underwent inguinal orchiectomy due to suspected testicular cancer in the two hospitals during the study period were included in our study&#46; Demographic and clinical data were reviewed retrospectively&#46; Benign pathologies were detected in 3 of 78 patients who underwent inguinal orchiectomy&#46; Lymphoma was detected in 2 patients and non-germ cell tumor was detected in 2 patients&#46; A total of 7 patients were excluded for standardization of the study and the study was continued with 71 patients&#46; All patients had the results of scrotal ultrasonography and tumor markers LDH &#40;lactate dehydrogenase&#41;&#44; AFP &#40;alpha-fetoprotein&#41;&#44; and B-hCG &#40;Beta-human chorionic gonadotropin&#41; tests at the time of diagnosis&#46; All preoperative or postoperative patients had radiological examinations for metastasis screening&#46; All patients were evaluated in terms of age&#44; complaint of presentation&#44; time from symptom onset to diagnosis &#40;DD&#41;&#44; radiological tumor size&#44; pathological tumor size&#44; tumor side&#44; presence of retroperitoneal LAP &#40;lymphadenopathy&#41;&#44; LDH&#44; AFP&#44; B-hCG values&#44; tumor being either seminoma or non-seminoma&#44; histological type of the tumor and TNM &#40;tumor-node-metastasis&#41; stages&#46; The relationship between the diagnosis delay time and tumor size&#44; level of tumor markers&#44; TNM stage&#44; presence of LAP&#44; and presence of metastasis were examined&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">A statistical program &#40;SPPS for Windows&#44; v21&#46;&#41; was used for data analysis&#46; The normal distribution of the data was evaluated with the Kolmogrov-Smirnov test&#44; histograms&#44; and skewness-Kurtosis coefficients&#46; Nominal and ordinal variables were compared with the Pearson chi-square test&#46; These data are given with numbers and percentages&#46; The correlations between the diagnosis delay time and different parameters were analyzed using the Spearman correlation test&#44; Pearson correlation test&#44; Student&#39;s t-test&#44; Mann-Whitney U&#44; and ANOVA tests&#46; The independent effects of diagnostic delay on pathological tumor size were examined using a univariate linear regression model&#46; Model of fit was examined using the required residual and fit statistics&#46; A value of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was accepted as statistically significant&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">The mean age of the 71 patients included in the study was 31&#46;27<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;87 years &#40;min&#58;16&#44; max&#58;53&#41;&#46; No difference was observed between the seminoma and non-seminoma groups in terms of age &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;371&#41;&#46; The most common presenting symptom of the patients was painless swelling of the testis &#40;38&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Seminoma tumors were detected in 39 &#40;54&#46;9&#37;&#41; patients and non-seminoma tumors were detected in 32 &#40;45&#46;1&#37;&#41; patients&#46; The sub-classification of non-seminoma tumors is presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The mean diagnostic delay time was determined as 31&#46;34<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&#46;87 days&#44; and no statistically significant difference was found between the seminoma and non-seminoma groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;420&#41;&#46; No significant relationship was found between the patient&#39;s complaint at admission and the diagnostic delay time &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;464&#41;&#46; The mean radiological tumor size of all patients was 40&#46;40<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;55<span class="elsevierStyleHsp" style=""></span>mm&#44; and the mean pathological tumor size was 40&#46;63<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;21<span class="elsevierStyleHsp" style=""></span>mm&#46; A strongly positive correlation was found between radiological and pathological tumor sizes and was statistically significant &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;869&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tables 1&#44; 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">There was no significant difference in terms of radiological and pathological tumor sizes between the seminoma and non-seminoma groups &#40;respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;461&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;388&#41;&#46; The tumor was detected in the right testis in 37 &#40;52&#46;1&#37;&#41; patients&#46; Retroperitoneal LAP was detected in 7 &#40;17&#46;9&#37;&#41; patients in the seminoma group and in 18 &#40;56&#46;3&#37;&#41; patients in the non-seminoma group&#46; In the non-seminoma group&#44; significantly higher rates of retroperitoneal LAP were detected &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; While AFP and B-hCG values were found to be significantly higher in the non-seminomatous group&#44; no statistically significant difference was observed between LDH levels &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;010&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;510&#44; respectively&#41;&#46; When the two groups were compared in terms of T and N stages&#44; significantly higher stages were found in the non-seminoma group &#40;respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; When M stages were compared&#44; no significant difference was observed between the two groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;416&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the correlation analysis between the markers&#44; a significant and positive correlation was found between the diagnostic delay time and radiological tumor size&#44; pathological tumor size&#44; retroperitoneal LAP detection rate&#44; LDH and AFP levels&#44; and N stage &#40;respectively&#59; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;345 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#44; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;324 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#44; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;244 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;041&#44; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;286 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;015&#44; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;244 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;040&#44; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;238 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;046&#41;&#46; Other markers that are thought to be correlated with each other are given in detail in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Based on the hypothesis that the increase in the diagnostic delay time has a significant and positive effect on the pathological size of the tumor&#44; the two data were evaluated by linear regression analysis &#40;enter method&#41;&#46; The model was statistically significant &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#46;113&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41; and could explain 10&#46;5&#37; of the variance in pathological tumor size without significant auto-correlation issues &#40;Durbin-Watson<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;659&#41;&#46; In the linear regression analysis&#44; diagnostic delay time was found to be a significant predictor of pathological tumor size&#46; According to the standardized regression coefficients &#40;&#946;&#41;&#44; a 1-day increase in the delay in diagnosis causes an increase of 0&#46;431<span class="elsevierStyleHsp" style=""></span>mm in the pathological size of the tumor &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Testicular cancer presents as GHT with a frequency of over 90&#37; and &#304;T has been reported as the most common malignancy in young male papulation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Although no significant difference was observed in terms of age between the groups in our study&#44; the mean age was found to be 31&#46;27<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;87 years&#44; consistent with the literature&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In an epidemiological study conducted at Ege University&#44; 45&#46;4&#37; of GHT cases were observed as seminoma and 54&#46;6&#37; as non-seminoma tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In a study of 439 patients conducted by Huyghe et al&#46;&#44; 45&#37; of the cases were found as seminoma and 55&#37; as non-seminoma&#46; In the same study&#44; the mean age at diagnosis of non-seminoma cases was 27&#46;7 years&#44; and the mean age of diagnosis of seminoma was 37 years&#44; and it was shown that non-seminoma cases were diagnosed significantly earlier&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> In our study&#44; 54&#46;9&#37; of the patients were in the seminoma group and 45&#46;1&#37; in the non-seminoma group&#44; and no statistically significant difference was found between the mean age of the groups&#46; Besides&#44; the mean diagnostic delay time was found to be 31&#46;34 days&#44; and there was no significant difference in diagnostic delay times between the groups&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The most common presentation of testicular cancer has been reported as painless unilateral swelling&#46; Also&#44; Huyghe et al&#46; reported painless swelling as the most common presenting symptom with a rate of 48&#37; in their studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;27</span></a> In our study&#44; compatible with the literature&#44; the most common presenting symptom was painless swelling with a rate of 38&#37;&#46; There was no significant relationship between the complaints at admission and the groups or on the diagnostic delay time&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As expected in accordance with the literature&#44; AFP and B-hCG values were found to be significantly higher in the non-seminoma group in our study&#44; but no statistically significant difference was observed between LDH levels&#46; Conducted studies have shown that non-seminomatous testicular tumors show a higher rate of retroperitoneal LAP positivity than seminomas at the time of diagnosis and they present with higher stages&#46; In our study&#44; while retroperitoneal LAP was present in 56&#37; of non-seminomas at the time of diagnosis&#44; this rate was 17&#37; in seminomas&#44; and this difference was statistically significant&#46; Also&#44; in the comparison made in terms of T and N stages&#44; patients in the non-seminoma group were observed to be in statistically significantly higher stages&#44; while no significant difference was observed in terms of M stages&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;27</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Tumor size has prognostic significance for testicular tumors&#44; especially for seminomatous tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> In our study&#44; the mean radiological tumor size of the patients was 40&#46;40<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;55<span class="elsevierStyleHsp" style=""></span>mm&#44; and the mean pathological tumor size was 40&#46;63<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;21<span class="elsevierStyleHsp" style=""></span>mm&#46; A strong level of positive correlation was observed between radiological and pathological tumor sizes&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The importance of early diagnosis in testicular tumors has been known and emphasized for many years&#46; In the times when curative treatments were not yet applied&#44; early diagnosis was perhaps the most important criterion for reducing mortality for testicular tumors&#46; Today&#44; although decreasing mortality rates are observed&#44; early diagnosis maintains its importance as the main factor in reducing morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Therefore&#44; many studies have been conducted to examine the factors that cause diagnostic delay&#46; The main reasons are patients&#39; education level&#44; socioeconomic status&#44; fear of cancer&#44; fear of organ loss&#44; active sexual life&#44; and doctor-mediated delay&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In the series of 542 patients examined by Huyghe et al&#46;&#44; it was shown that diagnostic delay was significantly associated with increased stage of disease in the general population and in the non-seminoma group&#46; Also&#44; despite the modern chemotherapy protocols applied in this study&#44; it was concluded that diagnostic delay still had a significant effect on survival&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In the studies by M&#46;D&#46; Anderson Cancer Center and Hernes et al&#46;&#44; the negative effects of diagnostic delay on survival were also shown&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;33</span></a> In another study in which diagnostic delay was associated with an increased need for adjuvant therapy&#44; diagnostic delay and tumor size were found to be associated with high serum marker levels&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> In our study&#44; in parallel with this data&#44; a significant and positive correlation was observed between diagnostic delay time and radiological tumor size&#44; pathological tumor size&#44; retroperitoneal LAP detection rate&#44; LDH and AFP levels&#44; and N stage&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Kobayashi et al&#46; showed that the diagnostic delay time was correlated with the tumor size at the time of diagnosis&#44; and this had negative effects on the survival of the patients&#44; especially in the non-seminoma group&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> In the linear regression analysis performed in our study&#44; it was determined that the delay in diagnosis was a significant predictor of pathological tumor size&#46; Accordingly&#44; a 1-day increase in the diagnostic delay caused an increase of 0&#46;431<span class="elsevierStyleHsp" style=""></span>mm in the pathological size of the tumor&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Mentioning the limitations of our study&#44; it can be said that the number of patients is small and the diagnostic delay time is open to subjective interpretation by patients in some instances&#46; The strengths of our study are that it was studied in a homogeneous patient group&#44; careful patient records were used&#44; tumor size and diagnostic delay time were evaluated by linear regression analysis</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Diagnostic delay time is still an important issue for testicular tumors&#46; Delay in diagnosis can be affected by many factors related to the disease and the person&#46; Delay in diagnosis not only causes an increase in tumor size but also negatively affects the tumor stage and prognostic factors&#46; We think that multicenter studies with a high number of patients in which these factors are also examined can contribute to the literature&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that there was no financial support for this study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethics approval and consent to participate</span><p id="par0115" class="elsevierStylePara elsevierViewall">This study was approved by the local ethics committee &#40;AFSU 2011-KAEK-2&#47;2023&#47;246&#41; and was conducted in accordance with the ethical standards of the Declaration of Helsinki&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Authors&#8217; contributions</span><p id="par0125" class="elsevierStylePara elsevierViewall">O&#46;G&#46; K&#46;T&#46; and K&#46;U designed the study&#59; O&#46;G&#44; K&#46;T and AK&#46;Y recruited the participants and collected the data&#59; O&#46;G&#44; K&#46;T&#44; AK&#46;Y performed the statistical analysis&#59; O&#46;G&#44; K&#46;T&#44; K&#46;U and V&#46;M&#46;Y interpreted the data&#59; O&#46;G&#44; K&#46;U&#44; AK&#46;Y and V&#46;M&#46;Y drafted the first manuscript&#59; and all authors critically reviewed the paper&#46;</p></span></span>"
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          "identificador" => "xpalclavsec1831400"
          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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    "fechaRecibido" => "2023-09-11"
    "fechaAceptado" => "2023-09-27"
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            0 => "Testis cancer"
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            2 => "Malignancy"
            3 => "TNM staging"
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            0 => "C&#225;ncer de test&#237;culo"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">In testicular cancer&#44; the positive effect of early diagnosis on survival has been known for many years&#46; In this study&#44; we aimed to determine the diagnostic features of testicular cancer patients&#44; to examine the effect of duration of diagnosis delay &#40;DD&#41; on tumor size&#44; tumor stage&#44; and serum tumor markers&#44; and to reveal the possible benefits of early diagnosis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">A total of 71 patients who underwent inguinal orchiectomy due to suspicion of testicular cancer and whose pathology was found to be the germ cell tumor were included in the study&#46; The relationship between the duration of diagnosis delay and tumor size&#44; level of tumor markers&#44; TNM stage&#44; presence of LAP&#44; and presence of metastasis were examined&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Seminoma was detected in 39 &#40;54&#46;9&#37;&#41; patients and non-seminoma tumor was detected in 32 &#40;45&#46;1&#37;&#41; patients&#46; In the correlation analysis between the markers&#44; a significant and positive correlation was found between DD and radiological tumor size&#44; pathological tumor size&#44; retroperitoneal LAP detection rate&#44; LDH and AFP levels&#44; and N stage &#40;respectively&#59; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;345 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#44; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;324 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#44; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;244 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;041&#44; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;286 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;015&#44; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;244 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;040&#44; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;238 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;046&#41;&#46; It was determined that a 1-day increase in DD caused an increase of 0&#46;431<span class="elsevierStyleHsp" style=""></span>mm in the pathological size of the tumor&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Duration of diagnosis delay is an issue that still keeps its importance for testicular tumors&#46; Delay in diagnosis not only leads to an increase in tumor size but also negatively affects tumor stage and prognostic factors&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Methods"
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            "identificador" => "abst0015"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">El impacto positivo del diagn&#243;stico precoz sobre la supervivencia del c&#225;ncer testicular es bien conocido desde hace muchos a&#241;os&#46; El objetivo de este estudio fue determinar las caracter&#237;sticas diagn&#243;sticas de los pacientes con c&#225;ncer testicular&#44; examinar el impacto del retraso en el diagn&#243;stico &#40;RD&#41; sobre el tama&#241;o del tumor&#44; el estadio tumoral y los marcadores tumorales s&#233;ricos&#44; e identificar los posibles beneficios del diagn&#243;stico precoz&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron en el estudio 71 pacientes sometidos a orquiectom&#237;a inguinal por sospecha de c&#225;ncer testicular&#44; cuya patolog&#237;a se confirm&#243; como tumor de c&#233;lulas germinales&#46; Se examin&#243; la relaci&#243;n entre el tiempo de retraso en el diagn&#243;stico y el tama&#241;o del tumor&#44; los niveles de los marcadores tumorales&#44; el estadio TNM&#44; la presencia de adenopat&#237;a &#40;ADP&#41; y de met&#225;stasis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Se detect&#243; seminoma en 39 &#40;54&#44;9&#37;&#41; pacientes y tumor no seminomatoso en 32 &#40;45&#44;1&#37;&#41; pacientes&#46; En el an&#225;lisis de correlaci&#243;n entre marcadores&#44; se encontr&#243; una correlaci&#243;n significativa y positiva entre el RD y el tama&#241;o tumoral determinado por pruebas radiol&#243;gicas &#40;tama&#241;o radiol&#243;gico&#41;&#44; el tama&#241;o tumoral determinado por el estudio patol&#243;gico &#40;tama&#241;o radiol&#243;gico&#41;&#44; la tasa de detecci&#243;n de ADP retroperitoneal&#44; los niveles de LDH y AFP&#44; y estadio N &#40;respectivamente&#59; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;345 p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#44; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;324 p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#44; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;244 p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#44; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;286 p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;015&#44; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;244 p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;040&#44; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;238 p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;046&#41;&#46; Se determin&#243; que un aumento de 1 d&#237;a en el RD provocaba un aumento de 0&#44;431<span class="elsevierStyleHsp" style=""></span>mm en el tama&#241;o patol&#243;gico del tumor&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">El tiempo de retraso en el diagn&#243;stico es un aspecto relevante en el contexto de los tumores testiculares&#46; El retraso en el diagn&#243;stico no s&#243;lo produce un aumento del tama&#241;o tumoral&#44; sino que tambi&#233;n afecta negativamente el estadio tumoral y los factores pron&#243;sticos&#46;</p></span>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pain in testis&nbsp;\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 &#40;15&#46;4&#41;&nbsp;\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 &#40;31&#46;3&#41;&nbsp;\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&#46;464&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Painless swelling&nbsp;\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 &#40;48&#46;7&#41;&nbsp;\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 &#40;25&#41;&nbsp;\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">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>&nbsp;\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;0&#41;&nbsp;\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 &#40;3&#46;1&#41;&nbsp;\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">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Incidental&nbsp;\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 &#40;2&#46;6&#41;&nbsp;\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 &#40;6&#46;3&#41;&nbsp;\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">&nbsp;\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">Diagnostic delay time&nbsp;\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">29&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>25&#46;34&nbsp;\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">34&#46;03<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#46;82&nbsp;\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&#46;420&nbsp;\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">Radiological tumor size &#40;mm&#41;&nbsp;\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">38&#46;87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#46;19&nbsp;\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">42&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>31&#46;97&nbsp;\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&#46;461&nbsp;\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">Pathological tumor size&nbsp;\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">38&#46;49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#46;38&nbsp;\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">43&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#46;19&nbsp;\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&#46;388&nbsp;\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 " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Side&nbsp;\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">&nbsp;\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">&nbsp;\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">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Right&nbsp;\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">21 &#40;53&#46;8&#41;&nbsp;\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">16 &#40;50&#41;&nbsp;\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&#46;747&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Left&nbsp;\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 &#40;46&#46;2&#41;&nbsp;\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">16 &#40;50&#41;&nbsp;\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">&nbsp;\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 " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Retroperitoneal LAP&nbsp;\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">&nbsp;\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">&nbsp;\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">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Present&nbsp;\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 &#40;17&#46;9&#41;&nbsp;\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 &#40;56&#46;3&#41;&nbsp;\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&#46;001&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Absent&nbsp;\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">32 &#40;82&#46;1&#41;&nbsp;\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 &#40;43&#46;7&#41;&nbsp;\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">&nbsp;\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 " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">AFP&nbsp;\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&#46;12&#42;&nbsp;\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">115&#42;&nbsp;\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">&#60;0&#46;001&nbsp;\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">B-hCG&nbsp;\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&#46;64&#42;&nbsp;\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&#46;94&#42;&nbsp;\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&#46;010&nbsp;\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">LDH&nbsp;\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">275&#42;&nbsp;\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">267&#46;5&#42;&nbsp;\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&#46;510&nbsp;\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 " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">T stage&nbsp;\t\t\t\t\t\t\n
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                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical data of the groups&#46;</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0130"
            "detalle" => "Table "
            "rol" => "short"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">r&#58; correlstion coeficcient&#44; LAP&#58; lymphadenopathy&#44; AFP&#58;alfa feto protein&#44; B-hCG&#58; beta-human chorionic gonadotropin&#44; LDH&#58; laktate dehydrogenase&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The sections in bold are statistically significant&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnostic delay &#40;days&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pathological tumor size&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">T stage&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N stage&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">M stage&nbsp;\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
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                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="middle">Diagnostic delay &#40;days&#41;</td><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="middle">Age</td><td class="td" title="\n
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                  \t\t\t\t">&#8722;0&#46;054&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="middle">Radiological tumor size &#40;mm&#41;</td><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="middle">RetroperitonealLAP</td><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="middle">Pathological tumor size</td><td class="td" title="\n
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                  """
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Dependent variable&#58; pathological tumor size&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">R&#58; 0&#46;324&#44; R<span class="elsevierStyleSup">2&#58;</span> 0&#46;105&#44; F&#58; 8&#46;113&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#44; Durbin-Watson&#58; 1&#46;659&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The sections in bold are statistically significant&#46;</p>"
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Article information
ISSN: 21735786
Original language: English
DOI:10.1016/j.acuroe.2023.11.004
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