Clinical case
Bilateral and synchronous testicular teratoma: a case report and literature review
Teratoma testicular bilateral sincrónico: reporte de un caso y revisión de la literatura
Pedro Matabuena-Tameza,
, Patricio Canepa-Fernándezb, Luis César Valencia-Garcíac, César Gutiérrez-Samperiod, Marco Alonso Gallegos-Coronae
Corresponding author
pmatabuena@hotmail.com
Corresponding author at: Prol. Privada Zaragoza 16, Torre 2 Consultorio 506, Santiago de Querétaro, C.P. 76030, Querétaro, Mexico. Tel.: +442 2153075; fax: +442 1923021.
Corresponding author at: Prol. Privada Zaragoza 16, Torre 2 Consultorio 506, Santiago de Querétaro, C.P. 76030, Querétaro, Mexico. Tel.: +442 2153075; fax: +442 1923021.
a Servicio de Cirugía Oncológica, Hospital Regional de Zona 1, Instituto Mexicano del Seguro Social, Santiago de Querétaro, Querétaro, Mexico
b Facultad de Medicina, Universidad Autónoma de Querétaro, Santiago de Querétaro, Querétaro, Mexico
c Servicio de Cirugía General, Centro Médico ABC, México, D.F., Mexico
d Investigación y Docencia, Universidad Autónoma de Querétaro, Santiago de Querétaro, Querétaro, Mexico
e Servicio de Patología, Hospital Regional de Zona 1, Instituto Mexicano del Seguro Social, Santiago de Querétaro, Querétaro, Mexico
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Privada Zaragoza 16, Torre 2 Consultorio 506, Santiago de Querétaro, C.P. 76030, Querétaro, Mexico. Tel.: +442 2153075; fax: +442 1923021." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Teratoma testicular bilateral sincrónico: reporte de un caso y revisión de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 695 "Ancho" => 995 "Tamanyo" => 139364 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Computed tomography scan. A retroperitoneal tumor of 6<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>cm is observed.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Testicular germ-cell carcinoma is the most frequent neoplasm in males aged 15–35<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a>; it is bilateral in 2–3%, and synchronous in 20–25% of cases.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> Approximately 80% of tumors are seminomas, and the remaining 20% have been identified as mixed teratomas, yolk sac tumors and both pure and mixed embryonal cell carcinomas.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> Most synchronous tumors are of the same histological type.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Medical records and physical examination are used in the diagnosis of testicular tumors. Generally the tumors present as a painless increase in intrascrotal volume, although 10% of patients present with acute pain. Diagnosis is commonly delayed due to the patient's reluctance to seek medical advice. Scrotal ultrasound testing is the most useful diagnostic tool, with tumor sensitivity in almost 100% of cases.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">α-Fetoprotein, lactate dehydrogenase and human chorionic gonadotropin tumor markers both assist diagnosis and enable tumor staging whilst simultaneously serving to aid follow-up and prognosis. They should be determined prior to orchiectomy, one week after surgery, and subsequent to the administration of chemotherapy, due to their kinetics and mean life span.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Tumor staging is the cornerstone to testicular cancer treatment. Computed tomography should therefore be used to assess probable metastases sites, sensitivity ranges from 70% to 80%.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> 10% of patients present with metastasis at the time of diagnosis.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">aim</span> of this article is to report a case of bilateral synchronous testicular teratoma, the first manifestation of which was a retroperitoneal tumor.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Clinical case</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 19 year-old male, with a family history of testicular cancer presented with sudden abdominal pain in the upper left quadrant. This was a moderate to severe, transfixing pain coming from the left iliac fosse, and was accompanied by repeated bouts of nausea and vomiting. Physical examination revealed a voluminous mesogastrium tumor which extended into deeper locations, and was accompanied by slight pain and no peritoneal irritation; the testicles were clinically with no palpable tumor activity. Abdominal X-rays showed the presence of the tumor and from the contrast-enhanced CT scan of the abdomen and pelvis we were able to determine its retroperitoneal location (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Tumor markers presented with a significantly elevated α-fetoprotein of 32,108.6<span class="elsevierStyleHsp" style=""></span>ng/ml, lactate dehydrogenase of 1184<span class="elsevierStyleHsp" style=""></span>U/l and fractionβ of human chorionic gonadotropin of 10,728<span class="elsevierStyleHsp" style=""></span>mIU/ml. Testicular ultrasound showed a complex bilateral lesion in the right testicle of 20<span class="elsevierStyleHsp" style=""></span>mm, and a solid, hypervascularised lesion of 19<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) in the left testicle.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Exploratory laparomoy was performed which revealed highly vascular, retroperitoneal malignancy, which had infiltrated the mesenterium and displaced all intestinal loops. Incisional biopsies were taken of the tumor, reporting mixed germ-cell tumor, with areas of choriocarcinoma and embryonal carcinoma (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Systemic treatment was initiated and 6 cycles of chemotherapy were administered with bleomycin, etoposide and cisplatin, with partial tumor response. After terminating chemotherapy the patient subsequently underwent bilateral radical orchiectomy with pathology reporting the presence of bilateral synchronous testicular teratoma. Unresectible retroperitoneal disease persisted (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The patient was administered a second line of chemotherapy, based on vincristine, etoposide, ifosfamide and cisplatinum. Nevertheless, the disease progressed, spreading to the liver and lung, and the patient died 2 years after diagnosis (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Germ cell tumors represent 95% of testicular cancers.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> They are rare diseases which mainly affect young adults and teenagers.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> An estimated 8,590 new cases are detected annually in the United States, with a survival rate of up to 5 years in 96%.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> Malignant testicular tumors rank twelfth in the number of hospital discharges for malignant tumors, according to the data base of the Registro Histopatológico de Neoplasias Malignas in Mexico.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Identifiable risk factors which predispose the development of germ cell tumors include: a prior history of testicular tumor; a family history of the disease; undescended testicles; testicular dysgenics, and Klinefelter syndrome.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> A change in the short arm of chromosome 12; i(12p) has been identified as a possible cause, and a mutation in gene DAD-R (apoptosis-inducing agent) has also been reported.).<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">15,16</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Primary presentation of these tumors may be extra-gonadal in location, due to embryonic origin and testicular descent. It is difficult to distinguish a retroperitoneum primary germ cell tumor from metastatic disease of a clinically undetected gonadal tumor or one that has regressed. This clinical condition is known as tumor burn-out.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> It is important to recall that initial signs of these tumors may be voluminous abdominal metastases, with no primary testicular tumor having been detected. This therefore delays diagnosis and treatment; examination and ultrasound imaging of the testicles are therefore important.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In the clinical case presented, there was no palpable tumor on examination but the doppler ultrasound scan revealed a complex, highly vascular cystic lesion in both testicles. This situation is considered infrequent, given that bilateral synchronous testicular cancer is extremely rare.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11,17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Based on the <span class="elsevierStyleItalic">American Joint Committee on Cancer</span> (AJCC) classification scale we could state that our case was a stage IIIC (pTXN3MOS3) when diagnosed.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> There is a risk classification scale for the patient with advanced disease, from the Grupo Colaborativo Internacional de Cáncer de Células Germinales. This classification takes several prognostic factors into account, including histological prognosis, the spread of the disease and the serum levels of the tumor markers, from which 3 risk groups are established: low, intermediate and high.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> In accordance with this classification our patient was in the high risk category.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The presence of an active tumor in the testicles after chemotherapy is a clearly proven fact, with the result that surgical exploration of the testicles and even orchiectomy are options to consider whilst taking into account individual patient characteristics.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> In our case inguinal extraction from the testicle was performed and transoperative tested biopsies were taken. Pathology reported testicular tumor, and we therefore decided to perform bilateral radical orchiectomy.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0085" class="elsevierStylePara elsevierViewall">Statistics show that approximately 90% of patients diagnosed with germ cell tumors can be cured. However, delay in diagnosis correlates with an advanced clinical stage and poor diagnosis.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The clinical evolution of the patient was slow, given the aggressive biological nature of the tumor, and late stage diagnosis. Despite treatment with chemotherapy and bilateral orchiectomy, the disease progressed and the patient died as a result.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres591728" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec607288" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres591727" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Discusión" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec607287" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-05-19" "fechaAceptado" => "2014-10-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec607288" "palabras" => array:3 [ 0 => "Synchronous bilateral testicular teratoma" 1 => "Metastases" 2 => "Testicular germ-cell carcinoma" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec607287" "palabras" => array:3 [ 0 => "Teratoma testicular sincrónico bilateral" 1 => "Metástasis" 2 => "Cáncer testicular de células germinales" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Testicular germ-cell carcinoma is the most frequent neoplasm in males aged 15–35 years old. It is bilateral in 2–3%, and synchronous in 20–25% of the cases.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical case</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The case is presented of a 19 year-old male, with abdominal pain. Physical examination revealed abdominal mass in the umbilical region, and the computed tomography scan showed a retroperitoneal tumor, with α-fetoprotein, lactate dehydrogenase, and human chorionic gonadotropin above limits. Testicular ultrasound showed bilateral lesions. Exploratory laparotomy was performed, identifying an unresectable retroperitoneal tumor. Biopsies were taken, reporting mixed germ cell tumor composed of choriocarcinoma and embryonal carcinoma. Six cycles of chemotherapy were given, based on bleomycin, etoposide and cisplatin, with partial tumor response. Later on, the patient underwent bilateral radical orchiectomy, with pathology reporting a synchronous bilateral testicular teratoma. A second line of chemotherapy was given, based on vincristine, etoposide, ifosfamide and cisplatinum. Nevertheless, the disease progressed, with metastatic dissemination and the patient died.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Germ cells tumors can be presented in primary extra-gonadal locations. It is difficult to distinguish a retroperitoneum primary germ cell tumor from metastatic disease of a clinically undetected gonadal tumor or one that has regressed, like the situation described in the case presented.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ninety percent of patients diagnosed with germ cell tumors can be cured. However, delay in diagnosis correlates with an advanced clinical stage and poor prognosis.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El cáncer testicular de células germinales es la neoplasia más frecuente en hombres de 15 a 35 años de edad; es bilateral en el 2 al 3%, y sincrónico en el 20 al 25% de los casos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Caso clínico</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Masculino de 19 años de edad, con dolor abdominal y tumor palpable en mesogastrio. En la tomografía se encontró un tumor retroperitoneal, y por laboratorio se detectó elevación de α-fetoproteína, deshidrogenasa láctica y gonadotropina coriónica humana. En el ultrasonido testicular se identifican lesiones bilaterales. Se realizó laparotomía exploradora, identificándose tumor retroperitoneal irresecable, y se tomaron biopsias incisionales compatibles para tumor de células germinales mixto, con áreas de coriocarcinoma y carcinoma embrionario. Se administraron 6 ciclos de quimioterapia con bleomicina, etopósido y cisplatino, obteniéndose una respuesta tumoral parcial. Posteriormente se realizó orquiectomía radical bilateral, con reporte patológico de teratoma bilateral sincrónico. Se inició segunda línea de quimioterapia con vincristina, etopósido, ifosfamida y platino; sin embargo, la enfermedad progresó, presentando diseminación metastásica y provocando el deceso del paciente.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discusión</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los tumores de células germinales pueden presentarse en sitios primarios extragonadales. Es difícil distinguir un tumor de células germinales primario del retroperitoneo, de una enfermedad metastásica derivada de un tumor gonadal no detectado clínicamente, o que ha involucionado, situación que se describe en el caso clínico presentado.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El 90% de los pacientes diagnosticados con tumor de células germinales pueden ser curados; sin embargo, un retraso en el diagnóstico se correlaciona con una etapa clínica más avanzada y un pronóstico desfavorable.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Discusión" ] 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: Matabuena-Tamez P, Canepa-Fernández P, Valencia-García LC, Gutiérrez-Samperio C, Gallegos-Corona MA. Teratoma testicular bilateral sincrónico: reporte de un caso y revisión de la literatura. Cirugía y Cirujanos. 2015;83:527–531.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 695 "Ancho" => 995 "Tamanyo" => 139364 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Computed tomography scan. A retroperitoneal tumor of 6<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>cm is observed.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 657 "Ancho" => 995 "Tamanyo" => 162178 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ultrasound scan of the right testicle which shows a cystic fine-tissued tumor with irregular hypoechoic areas.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 747 "Ancho" => 996 "Tamanyo" => 117069 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Biopsy of retroperitoneal tumor with extensive tumor necrosis and the presence of cyto-type and syncytiotrophoblast cell.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1269 "Ancho" => 950 "Tamanyo" => 156214 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Bilateral orchiectomy specimen, showing the presence of heterogenous neoplasic nodes with small cystic cavities.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 726 "Ancho" => 995 "Tamanyo" => 83141 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Computed tomography scan. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 25 | 7 | 32 |
| 2024 September | 36 | 3 | 39 |
| 2024 August | 27 | 3 | 30 |
| 2024 July | 21 | 4 | 25 |
| 2024 June | 19 | 12 | 31 |
| 2024 May | 16 | 4 | 20 |
| 2024 April | 13 | 30 | 43 |
| 2024 March | 34 | 8 | 42 |
| 2024 February | 44 | 10 | 54 |
| 2024 January | 39 | 7 | 46 |
| 2023 December | 37 | 4 | 41 |
| 2023 November | 30 | 7 | 37 |
| 2023 October | 19 | 16 | 35 |
| 2023 September | 22 | 2 | 24 |
| 2023 August | 20 | 5 | 25 |
| 2023 July | 27 | 7 | 34 |
| 2023 June | 17 | 4 | 21 |
| 2023 May | 29 | 23 | 52 |
| 2023 April | 12 | 2 | 14 |
| 2023 March | 37 | 4 | 41 |
| 2023 February | 26 | 3 | 29 |
| 2023 January | 18 | 5 | 23 |
| 2022 December | 22 | 6 | 28 |
| 2022 November | 26 | 15 | 41 |
| 2022 October | 27 | 10 | 37 |
| 2022 September | 18 | 15 | 33 |
| 2022 August | 23 | 20 | 43 |
| 2022 July | 14 | 10 | 24 |
| 2022 June | 19 | 11 | 30 |
| 2022 May | 14 | 5 | 19 |
| 2022 April | 14 | 8 | 22 |
| 2022 March | 11 | 7 | 18 |
| 2022 February | 17 | 7 | 24 |
| 2022 January | 31 | 5 | 36 |
| 2021 December | 31 | 11 | 42 |
| 2021 November | 37 | 11 | 48 |
| 2021 October | 24 | 10 | 34 |
| 2021 September | 13 | 9 | 22 |
| 2021 August | 12 | 11 | 23 |
| 2021 July | 19 | 10 | 29 |
| 2021 June | 17 | 11 | 28 |
| 2021 May | 26 | 8 | 34 |
| 2021 April | 57 | 18 | 75 |
| 2021 March | 20 | 14 | 34 |
| 2021 February | 9 | 8 | 17 |
| 2021 January | 16 | 12 | 28 |
| 2020 December | 19 | 9 | 28 |
| 2020 November | 10 | 7 | 17 |
| 2020 October | 14 | 7 | 21 |
| 2020 September | 16 | 12 | 28 |
| 2020 August | 17 | 8 | 25 |
| 2020 July | 14 | 10 | 24 |
| 2020 June | 14 | 8 | 22 |
| 2020 May | 19 | 7 | 26 |
| 2020 April | 13 | 3 | 16 |
| 2020 March | 8 | 4 | 12 |
| 2020 February | 17 | 4 | 21 |
| 2020 January | 9 | 8 | 17 |
| 2019 December | 23 | 7 | 30 |
| 2019 November | 11 | 5 | 16 |
| 2019 October | 16 | 4 | 20 |
| 2019 September | 16 | 8 | 24 |
| 2019 August | 8 | 1 | 9 |
| 2019 July | 16 | 11 | 27 |
| 2019 June | 34 | 28 | 62 |
| 2019 May | 86 | 23 | 109 |
| 2019 April | 32 | 12 | 44 |
| 2019 March | 12 | 8 | 20 |
| 2019 February | 17 | 4 | 21 |
| 2019 January | 17 | 7 | 24 |
| 2018 December | 7 | 4 | 11 |
| 2018 November | 11 | 4 | 15 |
| 2018 October | 9 | 5 | 14 |
| 2018 September | 10 | 6 | 16 |
| 2018 August | 4 | 4 | 8 |
| 2018 July | 5 | 3 | 8 |
| 2018 June | 4 | 1 | 5 |
| 2018 May | 3 | 1 | 4 |
| 2018 April | 5 | 4 | 9 |
| 2018 March | 2 | 1 | 3 |
| 2018 February | 8 | 1 | 9 |
| 2018 January | 10 | 1 | 11 |
| 2017 December | 14 | 2 | 16 |
| 2017 November | 9 | 3 | 12 |
| 2017 October | 7 | 5 | 12 |
| 2017 September | 16 | 11 | 27 |
| 2017 August | 7 | 5 | 12 |
| 2017 July | 22 | 6 | 28 |
| 2017 June | 19 | 24 | 43 |
| 2017 May | 16 | 4 | 20 |
| 2017 April | 7 | 31 | 38 |
| 2017 March | 10 | 62 | 72 |
| 2017 February | 10 | 5 | 15 |
| 2017 January | 13 | 0 | 13 |
| 2016 December | 17 | 5 | 22 |
| 2016 November | 15 | 5 | 20 |
| 2016 October | 20 | 6 | 26 |
| 2016 September | 7 | 7 | 14 |
| 2016 August | 25 | 8 | 33 |
| 2016 July | 13 | 4 | 17 |
| 2016 June | 26 | 18 | 44 |
| 2016 May | 18 | 15 | 33 |
| 2016 April | 29 | 14 | 43 |
| 2016 March | 46 | 11 | 57 |
| 2016 February | 47 | 29 | 76 |
| 2016 January | 24 | 26 | 50 |
| 2015 December | 12 | 7 | 19 |
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