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Original article
Direct-to-implant breast reconstruction after neoadjuvant chemotherapy: a safe option?
Reconstrucción inmediata mediante implante directo tras quimioterapia neoadyuvante. ¿Es una práctica segura?
Marta Allué Cabañuza,
Corresponding author
martitaallue@hotmail.com

Corresponding author.
, Maria Dolores Arribas del Amoa, Ismael Gil Romeaa, María Pilar Val-Carreres Riveraa, Ramón Sousa Domíngueza, Antonio Tomás Güemes Sáncheza,b
a Unidad de Mama, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
b Universidad de Zaragoza, Zaragoza, Spain
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using autologous or heterologous reconstruction and direct implants&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although several studies argue that IBR is feasible after skin-saving mastectomies in patients who have previously received neoadjuvant chemotherapy &#40;NACT&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> this is still controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of this retrospective case-control study is to analyze and compare complications&#44; sequelae and re-operation rates&#44; as well as oncological results&#44; between patients who have undergone NACT and bilateral mastectomy with immediate reconstruction &#40;BMIBR&#41; and those who did not&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To date&#44; no prospective&#44; matched&#44; case-control studies have been published about patients with breast reconstruction after neoadjuvant treatment&#46; Therefore&#44; this present study&#44; despite having the limitations of being a retrospective study&#44; is able to provide useful information that increases the number of indications for IBR after NACT&#44; which is proven to be safe&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A retrospective observational analysis was performed to identify patients who had undergone bilateral mastectomy as a treatment for breast cancer with direct prosthetic IBR at our hospital from 2000-2016&#46; From this group&#44; patients with BMIBR after NACT &#40;the NACT group&#41; were selected&#44; which were matched at a maximum ratio of 1&#58;5 versus patients who had not received NACT &#40;control group&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Data were collected for the following variable types&#58; demographic &#40;age&#59; comorbidities such as obesity&#44; HTN&#44; DM&#59; and active smoking&#41;&#59; clinical&#47;pathological &#40;indication&#44; clinical stage&#44; etc&#46;&#41;&#59; and surgical &#40;type of intervention&#44; reconstructive techniques used&#44; and postoperative morbidity&#41;&#46; Postoperative complications &#40;those that appeared within 30 days after the intervention&#41; and sequelae &#40;after 30 days&#41; were evaluated&#46; Likewise&#44; the oncological results were evaluated&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">This study adheres to the ethical principles of the Declaration of Helsinki and was approved by the Ethics Committee of our hospital and by the Clinical Research Ethics Committee of Aragon &#40;CEICA&#44; <span class="elsevierStyleItalic">Comit&#233; &#201;tico de Investigaci&#243;n Cl&#237;nica de Arag&#243;n</span>&#41; with registration number C&#46;P&#46;-C&#46;I&#46; PI16&#47;002&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patient Selection</span><p id="par0045" class="elsevierStylePara elsevierViewall">The inclusion criteria for BMIBR were&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">none&#8211;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Multicentric or multifocal carcinoma not treatable with conservative surgery&#46; Multifocality&#58; 2 or more tumor foci in the same quadrant and less than 5&#8201;cm from the primary focus&#59; and multicentricity&#58; 2 or more tumor foci in different quadrants of the same breast or more than 5&#8201;cm from the primary focus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">none&#8211;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Large <span class="elsevierStyleItalic">in situ</span> component of the infiltrating tumor&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">none&#8211;</span><p id="par0060" class="elsevierStylePara elsevierViewall">High risk due to family history &#40;no known mutation&#41;&#58; defined by 2 or more family members &#40;at least one a close relative with breast or ovarian cancer at an early age&#44; before the age of 50&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">none&#8211;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Known mutation in BRCA1 and BRCA2 genes&#46;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">Patients with inflammatory carcinoma&#44; as well as BMIBR with no present or past cancer &#40;pure prophylactic mastectomy&#41;&#44; were excluded&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The criteria we used for the administration of NACT &#40;regimens and durations&#41; were the updated guidelines and recommendations that were current at the time of treatment&#44; which varied over the course of the study&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients with distant metastases at the time of diagnosis and those with progression of the disease during NACT were excluded from the study because they did not undergo IBR after mastectomy&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Patients with tumors larger than 5&#8201;cm in diameter and&#47;or 4 or more positive axillary lymph nodes also received adjuvant radiotherapy&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical Technique</span><p id="par0090" class="elsevierStylePara elsevierViewall">The surgical technique involved resection of the breast tissue&#44; leaving thin skin flaps&#44; with variations in the skin incision and either complete preservation or a free nipple-areola complex &#40;NAC&#41; graft&#46; The incisions varied according to the size and configuration of the breast affected and the contralateral breast&#44; the size and location of the tumor&#44; previous scars and the surgeon&#8217;s preference&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">none&#8211;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Subcutaneous mastectomy through external lateral incision&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">none&#8211;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Modified Spira technique&#58; implant with a double shell&#44; using a de-epithelialized flap attached to the pectoralis major muscle and free NAC graft after negative intraoperative biopsy of the base of the nipple&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">none&#8211;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Skin-saving mastectomy following the short Wise pattern&#58; periareolar incision with vertical extension towards the inframammary fold and lateral and medial extension along the fold&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">none&#8211;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Skin-saving&#44; nipple-saving mastectomy through an external radial incision&#46;</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">IBR was performed using a silicone implant with an anatomical design&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Pathological Evaluation and Oncological Results</span><p id="par0120" class="elsevierStylePara elsevierViewall">The clinical stage was established according to the classification of the seventh edition of the AJCC&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">A complete clinical response was defined as the absence of palpable and&#47;or visible tumor on MRI after NACT&#46; Partial response was defined as tumor reduction&#46; Any increase in tumor size was considered progression of the disease&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The locoregional recurrence was defined as the appearance of a new tumor in the ipsilateral chest wall &#40;skin&#44; subcutaneous tissue or pectoral muscle&#41; or recurrence in the ipsilateral axilla&#44; supraclavicular lymph nodes&#44; or internal or subclavicular mammary chains&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Distant metastasis was defined as any recurrence in all other areas not included in the locoregional recurrence&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical Analysis</span><p id="par0140" class="elsevierStylePara elsevierViewall">To evaluate the differences between the groups under study&#44; the Chi-squared or Fisher&#8217;s tests were used in the case of qualitative variables&#44; and the Mann-Whitney <span class="elsevierStyleItalic">U</span> test or Student&#8217;s <span class="elsevierStyleItalic">t</span> test were used for quantitative variables according to normal criteria&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">To assess overall survival &#40;OS&#41;&#44; disease-free survival &#40;DFS&#41;&#44; distant metastasis-free survival &#40;DMFS&#41; and locoregional recurrence-free survival &#40;LRFS&#41;&#44; Kaplan-Meier curves and log-rank tests were used&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The primary point of the study was DFS&#59; different Cox regression models were adjusted to evaluate the time until the event&#46; A <span class="elsevierStyleItalic">P</span> value of &#46;05 was considered statistically significant&#46; The SPSS 22&#46;0 program was used for the entire study&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0155" class="elsevierStylePara elsevierViewall">During the study period&#44; 171 BMIBR interventions were performed to treat breast cancer at our hospital&#58; 62 patients &#40;36&#46;3&#37;&#41; had received NACT&#44; and 109 patients &#40;63&#46;7&#37;&#41; received no neoadjuvant treatment&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">General Results</span><p id="par0160" class="elsevierStylePara elsevierViewall">The patients had a mean age of 48&#46;3&#8201;&#177;&#8201;9&#46;8 years &#40;range 31&#8211;87&#41; at the time of surgery&#46; In the NACT group it was 46&#46;6&#8201;&#177;&#8201;7&#46;0 years &#40;range 31&#8211;61&#41;&#44; and in the control group it was 49&#46;3&#8201;&#177;&#8201;11&#46;0 years &#40;range 31&#8211;87&#41;&#44; <span class="elsevierStyleItalic">P</span>&#8201;&#61;&#8201; &#46;183&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the clinical-pathological data related to the tumor and the comorbidities that could affect the surgical technique as well as the development of complications&#46; The distribution of these factors among the study groups was homogeneous&#59; statistically significant differences were only found for HTN&#44; which was superior in the control group &#40;14&#46;7&#37; vs&#46; 3&#46;2&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8201;&#61;&#8201; &#46;020&#41;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">The indications for practicing a more frequent BMIBR in both groups was patient choice &#40;32&#46;7&#37;&#41;&#44; followed by multifocal disease &#40;27&#46;5&#37;&#41;&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">The median follow-up was 52&#46;0 &#40;IQR&#58; 23&#46;0&#8211;94&#46;0&#41; months&#44; 34&#46;5 &#40;IQR&#58; 13&#46;0&#8211;77&#46;3&#41; months for the NACT group and 62&#46;0 &#40;IQR&#58; 36&#46;5&#8211;110&#46;0&#41; for the control group&#44; respectively &#40;<span class="elsevierStyleItalic">P</span>&#8201;&#60;&#8201; &#46;001&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Surgical Techniques</span><p id="par0180" class="elsevierStylePara elsevierViewall">The distribution of the different types of reconstruction in the two study groups was homogeneous for purely technical reasons&#46; The treatment for each patient was individualized and the most suitable technique chosen&#46; No statistically significant differences were found&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">We present the results of the different techniques used in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Complications</span><p id="par0190" class="elsevierStylePara elsevierViewall">The overall complication rate was 29&#46;8&#37; for the entire group&#44; and there were no statistically significant differences between the two groups in terms of the complication rate&#58; 32&#46;2&#37; in the NACT group and 28&#46;4&#37; in the control group &#40;<span class="elsevierStyleItalic">P</span>&#8201;&#61;&#8201; &#46;44&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The most frequent postoperative complication was skin necrosis &#40;7&#46;6&#37;&#41;&#44; followed by maintained seroma &#40;7&#46;0&#37;&#41; and hematoma &#40;5&#46;8&#37;&#41;&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Skin necrosis was the most frequent in the NACT group&#44; and maintained seroma was the most frequent in the control group&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The reoperation rate in the early postoperative period was 1&#46;8 &#37; for the NACT group and 2&#46;3 &#37; for the control group &#40;<span class="elsevierStyleItalic">P</span>&#8201;&#61;&#8201; &#46;705&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Oncological Results</span><p id="par0205" class="elsevierStylePara elsevierViewall">8&#46;2&#37; of the patients died due to breast cancer during the study&#58; 7 from the NACT group &#40;11&#46;3&#37;&#41; and 7 from the control group &#40;6&#46;5&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">The Kaplan-Meier survival curves for OS &#40;log-rank test&#44; <span class="elsevierStyleItalic">P</span>&#8201;&#61;&#8201; &#46;016&#41;&#44; DFS &#40;log-rank test&#44; <span class="elsevierStyleItalic">P</span>&#8201;&#61;&#8201; &#46;005&#41;&#44; DMFS &#40;log-rank test&#44; <span class="elsevierStyleItalic">P</span>&#8201;&#61;&#8201; &#46;004&#41; and LRFS &#40;log-rank test&#44; <span class="elsevierStyleItalic">P</span>&#8201;&#61;&#8201; &#46;368&#41; are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">NACT Group</span><p id="par0215" class="elsevierStylePara elsevierViewall">The average OS was 46&#46;1 &#40;95&#37; CI&#58; 36&#46;2&#8211;55&#46;9&#41; months&#44; the average DFS was 40&#46;6 months &#40;95&#37; CI&#58; 31&#46;7&#8211;49&#46;5&#41;&#44; the average DMFS was 39&#46;8 months &#40;95&#37; CI&#58; 31&#46;2&#8211;48&#46;5&#41; and the average LRFS was 43&#46;0 months &#40;95&#37; CI&#58; 33&#46;5&#8211;52&#46;5&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Control Group</span><p id="par0220" class="elsevierStylePara elsevierViewall">The average OS was 75&#46;9 &#40;95&#37; CI&#58; 65&#46;8&#8211;86&#46;1&#41; months&#44; the average DFS was 72&#46;5 months &#40;95&#37; CI&#58; 62&#46;4&#8211;82&#46;6&#41;&#44; the average time of DMFS was 70&#46;8 &#40;95&#37; CI&#58; 60&#46;7&#8211;80&#46;9&#41; months and the average time of LRFS was 71&#46;3 &#40;95&#37; CI&#58; 61&#46;4&#8211;81&#46;2&#41; months&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">There were statistically significant differences between the groups for all variables except local recurrence&#46; The survival curves &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; and univariate analysis demonstrated that patients in the NACT group had 3 times more risk than patients in the control group for having recurrence at a certain moment in time &#40;3&#46;009&#59; 1&#46;349&#8211;6&#46;713&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0230" class="elsevierStylePara elsevierViewall">As a result of recent advances in chemotherapy treatments and agents targeting HER2&#44; the use of NACT has increased&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and the number of patients undergoing IBR after NACT has likewise grown&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The oncological safety of IBR skin-saving or skin-and-nipple-saving mastectomy conducted in patients with advanced stage breast cancer is still controversial&#44; especially when NACT is administered&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">In our study&#44; we found differences in OS&#44; DFS&#44; DMFS and LRFS between the 2 groups after being matched by age and clinical stage&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Many surgeons hesitate to perform IBR after NACT as it could increase the rate of complications&#44; which would result in the delayed administration of adjuvant treatments&#44; such as radiotherapy or trastuzumab&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Aurilio et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> reported significantly high local recurrence rates compared to the simple mastectomy group without reconstruction in estrogen-receptor negative patients&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">However&#44; many other studies have not shown a significant increase in complications in patients who underwent IBR after NACT&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;17</span></a> Song et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> reported that a meta-analysis including 11 studies showed that NACT does not increase the complication rate in patients with IBR&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">In a prospective study published by Donker et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> not only was no increase in short-term complications shown&#44; but these were significantly lower &#40;15&#37; vs&#46; 29&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8201;&#61;&#8201; &#46;042&#41; in patients with IBR after NACT compared to those who received adjuvant CTx after IBR&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">The results of our study are consistent with these data since we have found no statistically significant differences in terms of complication rates&#44; sequelae and&#47;or need for re-operation between the study groups&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Yes&#44; some differences were observed&#44; such as the increased risk of recurrence in patients of the NACT group&#44; which leads us to think that patients who receive NACT&#44; despite presenting a more unfavorable tumor stage&#44; are slightly younger and have fewer comorbidities&#44; which could affect the development of complications&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Although a prospective randomized controlled trial would be ideal&#44; there are many difficulties for performing IBR&#44; not only of a technical nature established by the surgeon but also in terms of patient preferences&#46; Furthermore&#44; it is difficult to accurately predict the clinical response to NACT&#44; which makes surgical planning difficult&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">There have been few matched case-control studies similar to ours&#46; Therefore&#44; studies of this type provide useful information&#44; allowing for the number of IBR indications after NACT to be increased&#44; as it is proven to be safe&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">However&#44; there are several limitations in this study that do not allow the results to be generalized&#46; First of all&#44; it is a retrospective study&#44; with a relatively short follow-up time considering the current breast cancer survival times&#46; Secondly&#44; since it is the experience of a single institution&#44; the sample size is small to establish an accurate analysis of the oncological results&#46; In addition&#44; the difference in follow-up in both groups is also a limitation to generalize the results&#46; It would be necessary to carry out multicenter studies with a longer follow-up times to be able to generalize them&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0295" class="elsevierStylePara elsevierViewall">IBR using direct prosthesis after skin-saving mastectomy may be a viable treatment option for patients with breast cancer receiving NACT&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">These patients have an increased risk of local recurrence&#44; but long-term follow-up data is needed to accurately assess cancer outcomes&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0305" class="elsevierStylePara elsevierViewall">This study has received no funding&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of Interests</span><p id="par0310" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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            2 => "Direct-to-implant"
            3 => "Neoadjuvant chemotherapy"
            4 => "Complications"
            5 => "Reoperation"
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          "titulo" => "Palabras clave"
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          "palabras" => array:6 [
            0 => "Mastectom&#237;a bilateral"
            1 => "Reconstrucci&#243;n inmediata"
            2 => "Implante directo"
            3 => "Quimioterapia neoadyuvante"
            4 => "Complicaciones"
            5 => "Reintervenci&#243;n"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Immediate reconstruction &#40;IBR&#41; after mastectomy in patients who have received neoadjuvant chemotherapy &#40;NACT&#41; remains controversial&#46; The aim of this study is to analyze and compare oncological results as well as complication and reoperation rates in patients undergoing NACT and a control group&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Retrospective observational case-control study of patients with breast cancer who underwent bilateral mastectomy and direct-to-implant IBR &#40;BMIBR&#41; from 2000-2016&#46; The group that received NACT was matched 1&#58;5 to patients without NACT &#40;Control group&#41;&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">We evaluated differences between groups using the Chi-squared or Fisher test &#40;qualitative variables&#41;&#44; Mann-Whitney U or Student&#8217;s <span class="elsevierStyleItalic">t</span>-test &#40;quantitative variables&#41;&#46; The survival analysis was performed using Kaplan-Meier curves and log-rank test &#40;SPSS 22&#46;0&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The study included a total of 171 patients with BMIBR&#58; 62 patients &#40;36&#46;3&#37;&#41; after NACT and 109 patients &#40;63&#46;7&#37;&#41; in the control group without NACT&#46; Median follow-up was 52&#46;0 &#40;IQR&#58; 23&#46;0&#8211;94&#46;0&#41; months&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">In both groups&#44; the indication for BMIBR was patient choice &#40;32&#46;7&#37;&#41;&#46; There were no statistically significant differences between groups in terms of complication rate &#40;24&#46;2&#37; in the NACT group and 19&#46;3&#37; in the control group &#91;P&#8201;&#61;&#8201;&#46;44&#93;&#41;&#44; but differences in oncological results were found&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Patients in the NACT Group had three times more risk of recurrence at a given time than patients in the control group &#40;3&#46;009 &#91;1&#46;349&#8211;6&#46;713&#93;&#41; according to the univariate analysis&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Direct-to-implant IBR after skin-sparing mastectomy is a viable option for breast cancer patients undergoing neoadjuvant chemotherapy&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Introduction"
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            "titulo" => "Methods"
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            "identificador" => "abst0020"
            "titulo" => "Results"
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            "identificador" => "abst0025"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">La reconstrucci&#243;n inmediata &#40;RMI&#41; tras mastectom&#237;a en pacientes que han recibido quimioterapia neoadyuvante &#40;QTNA&#41; sigue siendo controvertida&#46; El objetivo de este estudio es analizar y comparar resultados oncol&#243;gicos y las tasas de complicaciones y reintervenci&#243;n en pacientes sometidas a QTNA y un grupo control&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todos</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis observacional retrospectivo de casos-controles&#46; Pacientes con c&#225;ncer de mama intervenidas de MBRMI mediante pr&#243;tesis directa durante el periodo 2000-2016&#46; Grupo que recibi&#243; QTNA emparejadas m&#225;ximo 1&#58;5 a las pacientes sin QTNA &#40;Grupo control&#41;&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Evaluamos diferencias entre grupos mediante test Chi 2 o Fisher &#40;variables cualitativas&#41;&#44; U de Mann Whitney o T Student &#40;variables cuantitativas&#41;&#46;An&#225;lisis de supervivencia mediante curvas de Kaplan&#8211;Meier y test de log-rank&#46;SPSS 22&#46;0&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Un total de 171 pacientes con MBRMI&#44; 62 pacientes &#40;363&#37;&#41; tras QTNA y 109 pacientes &#40;63&#46;7&#37;&#41; en grupo control sin QTNA&#46; Mediana de seguimiento de 52&#44;0 &#40;RIQ&#58;23&#44;0-94&#44;0&#41;meses&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">La indicaci&#243;n para practicar una MBRMI m&#225;s frecuente en ambos grupos es la elecci&#243;n de la paciente &#40;32&#46;7&#37;&#41;&#46;No hubo diferencias estad&#237;sticamente significativas entre los grupos en cuanto a tasa de complicaciones &#91;24&#46;2&#37; en el grupo QTNA y 19&#46;3&#37; en grupo control &#40;P&#8201;&#61;&#8201;0&#44;44&#41;&#93;&#46;</p><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">S&#237; existen diferencias en resultados oncol&#243;gicos&#46; Las pacientes del Grupo QTNA tienen tres veces m&#225;s riesgo que las pacientes del grupo control de presentar recidiva en un momento determinado del tiempo 3&#44;009 &#40;1&#44;349-6&#44;713&#41; seg&#250;n an&#225;lisis univariante&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">La RMI mediante pr&#243;tesis directa tras mastectom&#237;as ahorradoras de piel es una opci&#243;n viable de tratamiento para pacientes con c&#225;ncer de mama sometidas a quimioterapia neoadyuvante&#46;</p></span>"
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          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Conclusiones"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Please cite this article as&#58; Allu&#233; Caba&#241;uz M&#44; Arribas del Amo MD&#44; Gil Romea I&#44; Val-Carreres Rivera MP&#44; Sousa Dom&#237;nguez R&#44; G&#252;emes S&#225;nchez AT&#46; Reconstrucci&#243;n inmediata mediante implante directo tras quimioterapia neoadyuvante&#46; &#191;Es una pr&#225;ctica segura&#63; Cir Esp&#46; 2019&#59;97&#58;575&#8211;581&#46;</p>"
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          0 => array:4 [
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Kaplan&#8211;Meier Curves&#58; A&#41; Exitus&#59; B&#41; Recurrence&#59; C&#41; Distant recurrence&#59; D&#41; Local recurrence&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;554<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>HTN</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#46;020</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;31&#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">&#46;613&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">Infiltrating lobular carcinoma &#40;patient choice&#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">24 &#40;14&#46;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">6 &#40;9&#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">18 &#40;16&#46;5&#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">&#46;258&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">Multicentricity&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">20 &#40;11&#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">3 &#40;4&#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">17 &#40;15&#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"><span class="elsevierStyleBold">&#46;046</span>&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">Ductal carcinoma <span class="elsevierStyleItalic">in situ</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">13 &#40;7&#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">3 &#40;4&#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">10 &#40;9&#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">&#46;380&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">Elevated family risk&#44; with no known mutation&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;4&#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">0 &#40;0&#46;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">7 &#40;6&#46;&#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"><span class="elsevierStyleBold">&#46;049</span>&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">BRCA1 and 2 gene mutations&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;3&#46;5&#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">4 &#40;6&#46;5&#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;1&#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">&#46;191&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Technique&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complete Series &#40;N&#8201;&#61;&#8201;171&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">NACT Group &#40;n&#8201;&#61;&#8201;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Control Group &#40;n&#8201;&#61;&#8201;109&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&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
                  \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">External lateral subcutaneous incision&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">77 &#40;45&#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">25 &#40;40&#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">52&#40;47&#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">&#46;750&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">Spira technique&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">71 &#40;41&#46;5&#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">27 &#40;43&#46;5&#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">44 &#40;40&#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">&#46;748&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">Short Wise pattern&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;12&#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">10 &#40;14&#46;5&#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">11 &#40;10&#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">&#46;460&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">External radial incision&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;1&#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">0 &#40;0&#46;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">2 &#40;1&#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">&#46;535&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complete Series &#40;N&#8201;&#61;&#8201;171&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">NACT Group &#40;n&#8201;&#61;&#8201;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Control Group &#40;n&#8201;&#61;&#8201;109&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&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
                  \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">Skin necrosis&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">13 &#40;7&#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">6 &#40;3&#46;5&#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">7 &#40;4&#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">&#46;550&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">Infection&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 &#40;5&#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">3 &#40;1&#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">6 &#40;3&#46;5&#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&#46;000&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">Maintained seroma&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">12 &#40;7&#46;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">4 &#40;2&#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">8 &#40;4&#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">1&#46;000&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">Hematoma&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;5&#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">4 &#40;2&#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">6 &#40;3&#46;5&#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&#46;000&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">Re-operation&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;4&#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">3 &#40;1&#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">4 &#40;2&#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">&#46;705&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Oncological Results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">NACT Group &#40;n&#8201;&#61;&#8201;62&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \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">Locoregional recurrence&nbsp;\t\t\t\t\t\t\n
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                  \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;4&#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">3 &#40;4&#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">4 &#40;3&#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">&#46;705&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
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                  \t\t\t\t">Distant metastasis&nbsp;\t\t\t\t\t\t\n
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                  \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;12&#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">11 &#40;17&#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">10 &#40;9&#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">&#46;144&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="elsevierStyleItalic">Exitus</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;8&#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">7 &#40;11&#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">7 &#40;6&#46;5&#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">&#46;384&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
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                  \t\t\t\t">Recurrence&nbsp;\t\t\t\t\t\t\n
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                  \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">25 &#40;14&#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">13 &#40;21&#46;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">12 &#40;11&#46;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">&#46;113&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">NACT yes&#47;no</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Control group&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ref&nbsp;\t\t\t\t\t\t\n
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                  \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>NACT group&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;007</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;009&nbsp;\t\t\t\t\t\t\n
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                  \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;349-6&#46;713&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
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;&#8201;35&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>35-50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III-IV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;749-44&#46;737&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;206-1&#46;751&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Negative&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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es en pt

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