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Juvenile nasopharyngeal angiofibroma with orbital extension
Angiofibroma nasofaríngeo juvenil con extensión orbitaria
A. Hervás Ontiverosa,
, E. España Gregoria, L. Climent Vallanoa, S. Rivas Roderob, A. Alamar Velázquezc, J.A. Simal Juliánd
Corresponding author
a Unidad docente de Oftalmología, Departamento de Cirugía, Universidad de Valencia, Hospital Universitario La Fe, Valencia, Spain
b Departamento de Anatomía Patológica, Hospital Universitario La Fe, Valencia, Spain
c Departamento de Otorrinolaringología, Hospital Universitario La Fe, Valencia, Spain
d Departamento de Neurocirugía, Hospital Universitario La Fe, Valencia, Spain
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Hervás Ontiveros, E. España Gregori, L. Climent Vallano, S. Rivas Rodero, A. Alamar Velázquez, J.A. Simal Julián" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Hervás Ontiveros" "email" => array:1 [ 0 => "anheront@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "España Gregori" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Climent Vallano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "S." "apellidos" => "Rivas Rodero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "Alamar Velázquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "J.A." "apellidos" => "Simal Julián" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad docente de Oftalmología, Departamento de Cirugía, Universidad de Valencia, Hospital Universitario La Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Anatomía Patológica, Hospital Universitario La Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Otorrinolaringología, Hospital Universitario La Fe, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Neurocirugía, Hospital Universitario La Fe, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Angiofibroma nasofaríngeo juvenil con extensión orbitaria" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 522 "Ancho" => 2001 "Tamanyo" => 407344 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Histological sections in hematoxylin–eosin of the ethmoid bone and paranasal sinus patient samples. (A) 10× increase samples showing a typical proliferation with prominent spindle cells arranged in fascicles. (B and C) 10× increase with PAS staining showing tumoration comprised by dilated blood vessels with irregular muscular walls covered by prominent endothelium.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Juvenile nasopharyngeal angiofibroma (JNA) is a locally invasive benign tumor which almost exclusively originates in the posterior area of the nasal cavity. It expresses in preferably male teenage patients and accounts for less than 0.5% of head and neck growths.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> It corresponds to a vascular lesion the growth of which erodes the bone structures in the base of the skull with the ability to extend to the nose, paranasal sinus and orbit. Intracranial invasion has also been described.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The case of a patient with orbit involvement and intracranial extension due to intracranial extension of nasopharyngeal angiofibroma with ethmoidal origin is presented.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinical case</span><p id="par0015" class="elsevierStylePara elsevierViewall">A male, 21 years of age, without relevant history, presented with left exophthalmos and diplopia in extreme gaze positions with 2 weeks evolution, without clinic of epistaxis or nasal obstruction (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Visual acuity was 20/20 in both eyes and intraocular pressure (IOP) 24<span class="elsevierStyleHsp" style=""></span>mmHg in left eye (LE) without limitations in ocular movement. Ocular fundus did not reveal alterations. Cerebral-orbitary magnetic resonance (MR) exhibited a highly vascularized left ethmoidal lesion with prominent vascular structures. Orbitary extension was observed with intra- and extraconal components which displaced the internal and inferior rectus. Ethmoidal cells exhibited bone destruction and extension toward the anterior cranial fossa, associating contrast capturing in the adjacent dural meningeal zone (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Arteriography revealed a highly vascularized tumor at the ethmoidal level, discarding the presence of arteriovenous malformations (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The remainder of the extension study was negative.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Initially and in the light of the clinical behavior and radiological findings an anterosuperior biopsy was performed, with the result of abundant bleeding. For this reason it was decided to postpone the intervention in order to approach the lesion through the anterior and nasal endoscopic path.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lesion biopsy exhibited the presence of capillary and venous blood vessels with irregular muscular walls which in addition were dilated and covered by prominent endothelium. Said vessels were surrounded by spindle cells with oval nucleii but without atypical mitosis. Associated inflammatory infiltrate was found which produced necrosis and destruction in the ethmoid bone tissue with extension toward the adjacent sinus mucosa and intracranially toward the dura mater (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The immunohistochemical study revealed angiomatous and fibroblastic properties with positive staining against smooth muscle vimentin, CD34, bcl-2, CD99, actin and myosin.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The sample analysis enabled the JNA diagnostic. Surgical approach was decided by means of anterosuperior and endoscopic orbitotomy. When the region was accessed, significant bleeding was evidenced and the tumor was partially resected. One week post-surgery MR revealed an intra-orbit nodule suggesting tumor remains and persistence of contrast capture at the frontal dural level (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Subsequently, a left orbit ethmoidal endonasal approach was decided to achieve almost complete removal of the mass and medial wall reconstruction (LactoSorb<span class="elsevierStyleSup">®</span> Plating System, Biomet Microfixation, Jacksonville, FL, USA). Postop. MR revealed a small left frontal post-surgery collection with small nodular capture at the meningeal level (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). Proptosis exhibited significant improvement, and ocular parallelism was maintained with discreet exophthalmos without diplopia. IOP in the LE improved to 16<span class="elsevierStyleHsp" style=""></span>mmHg.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Although the exact nature of JNA is not known, the first histological studies suggested it could originate in fibrocartilage, periosteum or embryonary fascia. Subsequently, Liang et al. reviewed a series of 25 tumors which concluded a vascular origin.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">JNA is a benign neoplasia with local malignity characteristics due to its ability to invade adjacent areas. In the present case, onset comprised orbit extension expression without nasal clinic, exhibiting diplopia in extreme positions due to compromised space. In this way, the tumor invaded the posterior portion of the orbits through the media wall from the ethmoidal <span class="elsevierStyleItalic">lamina papyracea</span>.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnostic is based on clinical findings and imaging tests which also determine the tumor extension.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> A differential diagnostic must be performed with other types of nasopharyngeal tumors (choanal polyp, adenoid hyperplasia), syphilis and nasopharyngeal tuberculosis, craniopharyngioma or lymphoma, among others.</p><p id="par0050" class="elsevierStylePara elsevierViewall">JNA is a therapeutic problem due to the risk of abundant bleeding and high recurrence rates. In general, surgical treatment is preferred with or without presurgery embolization. In recent years, endoscopic surgery is the treatment of choice as it allows satisfactory resections with the advantage of being able to see several angles of adjacent structures.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In the present case, the endonasal approach facilitated control of the intra-surgery bleeding and satisfactory tumor resection. Radiotherapy allowed control of the disease in highly advanced stages. At present, after a follow-up of one year, the patient has not exhibited relapses of the disease and has been referred to our practice every 6 months.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">No conflict of interest has been declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres471103" "titulo" => "Abstract" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Clinical case" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Discussion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec493601" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres471102" "titulo" => "Resumen" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Discusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec493600" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-07-15" "fechaAceptado" => "2014-02-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec493601" "palabras" => array:6 [ 0 => "Angiofibroma/diagnosis" 1 => "Angiofibroma/surgery" 2 => "Ocular neoplasms" 3 => "Invasion" 4 => "Exophthalmos" 5 => "Endoscopy/methods" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec493600" "palabras" => array:6 [ 0 => "Angiofibroma/diagnóstico" 1 => "Angiofibroma/cirugía" 2 => "Neoplasias oculares" 3 => "Invasión" 4 => "Exoftalmos" 5 => "Endoscopia/métodos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical case</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The case of a 21-year-old male with a history of left proptosis and diplopia of two weeks of onset is presented. The MRI showed an ethmoid-orbital vascular lesion with anterior skull base invasion and orbital extension. Biopsy of the ethmoid confirmed fibrovascular tissue, which supported the diagnosis of angiofibroma.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">It is a benign neoplasm with local characteristics of malignancy due to its ability to invade adjacent areas. In this case, the debut presented with manifestations of orbital extension. A broad and multidisciplinary approach is needed in order to improve prognosis.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Clinical case" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Discussion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Caso clínico</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Varón de 21 años con historia de exoftalmos izquierdo y diplopía de 2 semanas de evolución. La resonancia magnética mostró una lesión muy vascularizada etmoido-orbitaria con invasión de base del cráneo anterior y extensión orbitaria. La biopsia etmoidal confirmó un tejido fibrovascular compatible con angiofibroma.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discusión</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El angiofibroma nasofaríngeo juvenil (ANJ) es un tumor benigno con características locales de malignidad debido a su capacidad de invadir áreas adyacentes. En nuestro caso, el comienzo se presenta con manifestaciones de extensión orbitaria. Consideramos necesario un conocimiento amplio y un abordaje multidisciplinario con el fin de mejorar el pronóstico.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Discusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hervás Ontiveros A, España Gregori E, Climent Vallano L, Rivas Rodero S, Alamar Velázquez A, Simal Julián JA. Angiofibroma nasofaríngeo juvenil con extensión orbitaria. Arch Soc Esp Oftalmol. 2015;90:22–25.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 276 "Ancho" => 995 "Tamanyo" => 71870 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Left ocular proptosis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1411 "Ancho" => 1502 "Tamanyo" => 161775 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">MR pondered in T1 with contrast, axial section showing highly vascularized lesion with ethmoid-orbit occupation.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 974 "Ancho" => 996 "Tamanyo" => 105265 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Internal and external left carotid selective cerebral arteriography showing orbit vascular lesion with ethmoidal branch contribution from the ophthalmic artery and distal branches of the left internal maxillary artery.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 522 "Ancho" => 2001 "Tamanyo" => 407344 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Histological sections in hematoxylin–eosin of the ethmoid bone and paranasal sinus patient samples. (A) 10× increase samples showing a typical proliferation with prominent spindle cells arranged in fascicles. (B and C) 10× increase with PAS staining showing tumoration comprised by dilated blood vessels with irregular muscular walls covered by prominent endothelium.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1760 "Ancho" => 1502 "Tamanyo" => 169293 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">MR pondered in T1, coronal section evidencing rough dural capture at the anterior frontal level as well as intra-orbit nodule suggesting tumor remains.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 879 "Ancho" => 900 "Tamanyo" => 102903 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Post-surgery MR pondered in T1, coronal section illustrating near complete disappearance of the tumor mass, with persistence of small nodular image in the anterior meningeal base.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vision recovery following nasopharyngeal angiofibroma excision" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.A. Patrocinio" 1 => "L.G. Patrocinio" 2 => "L.P. Martins" 3 => "A.R. da Cunha" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Auris Nasus Larynx" "fecha" => "2002" "volumen" => "29" "paginaInicial" => "309" "paginaFinal" => "311" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12167458" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Juvenile nasopharyngeal angiofibroma: The routes of invasion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L.U. Sennes" 1 => "O. Butugan" 2 => "T.G. Sánchez" 3 => "R.F. Bento" 4 => "D.H. 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Jamal" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Arch Otorhinolaryngol" "fecha" => "1994" "volumen" => "251" "paginaInicial" => "241" "paginaFinal" => "245" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7917259" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intranasal endoscopic excision of a juvenile angiofibroma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.T. Mitskavich" 1 => "R.L. Carrau" 2 => "C.H. Snyderman" 3 => "J.L. Weissman" 4 => "J.J. Fagan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Auris Nasus Larynx" "fecha" => "1998" "volumen" => "25" "paginaInicial" => "39" "paginaFinal" => "44" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9512793" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735794/0000009000000001/v2_201504040216/S2173579415000055/v2_201504040216/en/main.assets" "Apartado" => array:4 [ "identificador" => "5812" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Short communications" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735794/0000009000000001/v2_201504040216/S2173579415000055/v2_201504040216/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579415000055?idApp=UINPBA00004N" ]
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