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Original article
Follow-up and results in patients with differentiated thyroid carcinoma in Castilla-La Mancha (2001–2015). The CADIT-CAM study
Resultados del seguimiento de pacientes con carcinoma diferenciado de tiroides en Castilla-La Mancha (2001–2015). Estudio CADIT-CAM
Julia Sastre Marcosa,
Corresponding author
jsastrem@sescam.jccm.es

Corresponding author.
, Silvia Aznarb, Visitación Álvarezc, Belvis Torresd, Manuel Delgadoe, Javier Gonzálezf, Iván Quirogag,
a Servicio de Endocrinología, Complejo Hospitalario de Toledo, Toledo, Spain
b Servicio de Endocrinología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
c Unidad de Endocrinología, Hospital Universitario de Guadalajara, Guadalajara, Spain
d Sección de Endocrinología, Hospital General Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
e Sección de Endocrinología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
f Sección de Endocrinología, Hospital Virgen de la Luz, Cuenca, Spain
g Sección de Endocrinología, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Thyroid carcinoma is the most common endocrine neoplasm and comprises a number of different tumour types characterized by variable clinical behaviour and prognoses&#46; Tumours originating from the thyroid follicular cells account for over 90&#37; of these neoplasms and are known as differentiated thyroid carcinoma &#40;DTC&#41;&#46; Although DTC is not a frequent neoplasm&#44; it accounts for 3&#37; of all tumours in females and 1&#37; in males&#46; Its incidence has increased exponentially in recent decades&#44; particularly in developed countries&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#8211;3</span></a> and Spain has been no exception to this worldwide increase&#46; Based on different methods&#44; studies in Galicia&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> Murcia<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> and Navarre<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> have demonstrated a sustained increase in the incidence of DTC since the 1980s&#46; In Spain&#44; thyroid cancer ranks second as the malignancy with the most favourable prognosis&#44; the overall 5-year survival rate in adults being 87&#46;4&#37;&#44; with better figures in women &#40;89&#46;8&#37;&#41; than in men &#40;78&#46;3&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> The above data suggest an immediate future characterized by a significant and growing number of patients with thyroid cancer&#44; who moreover will need adequate management&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The great advances in our knowledge of thyroid cancer have led to changes in the approach to the management of the disease&#44; as reflected in the new guidelines published in recent years&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;9</span></a> However&#44; many clinical&#44; diagnostic and therapeutic aspects of DTC continue to generate controversy and require us to continuously improve and unify the patient management protocols&#46; Awareness of the current situation in this field may help us in planning future strategies at both the clinical &#8211; healthcare level and in research&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A number of Spanish national series have already been published&#44; describing the characteristics and outcomes of patients treated for DTC in certain areas<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#8211;13</span></a> and regions of the country&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#44;14&#44;15</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In order to further our understanding of the clinical reality of patients with thyroid cancer&#44; the Society of Endocrinology&#44; Nutrition and Diabetes of Castilla-La Mancha &#40;Sociedad Castellano Manchega de Endocrinolog&#237;a Nutrici&#243;n y Diabetes &#91;SCAMEND&#93;&#41; decided to conduct a retrospective study to assess the profile of DTC in our geographical setting&#46; The CADIT-CAM study on differentiated thyroid carcinoma in Castilla-La Mancha was designed to evaluate the characteristics&#44; treatments and clinical outcomes of patients diagnosed with DTC over a 15-year period between 2001 and 2015 in the Autonomous Community of Castilla-La Mancha&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A retrospective study was made of patients with DTC &#40;derived from the follicular epithelium&#58; primary histological type either papillary or follicular&#41; diagnosed or operated upon between 1 January 2001 and 31 December 2015 in any of the healthcare areas of Castilla-La Mancha&#46; We included patients diagnosed and followed-up on at 7 reference hospitals of the 8 healthcare areas of this Autonomous Community &#40;Complejo Hospitalario Universitario de Albacete&#44; Hospital General Universitario de Ciudad Real&#44; Hospital Virgen de la Luz de Cuenca&#44; Hospital Universitario de Guadalajara&#44; Hospital General Mancha-Centro de Alc&#225;zar de San Juan&#44; Hospital Nuestra Se&#241;ora del Prado de Talavera de la Reina and Complejo Hospitalario de Toledo&#41;&#46; These hospitals cover over 95&#37; of the population in the region&#46; The data were collected or updated during 2017&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The following variables were analyzed&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Demographic characteristics&#58; gender&#44; date of birth&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Tumour-related characteristics at diagnosis&#58; the date of diagnosis was defined as the date of surgery or the date of fine needle aspiration biopsy &#40;FNAB&#41; of the suspected nodule in patients not undergoing surgery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Initial treatment provided&#58; the type of thyroid surgery &#40;total thyroidectomy&#44; subtotal thyroidectomy&#44; two-stage total thyroidectomy&#41;&#44; lymphadenectomy&#44; and radioiodine treatment &#40;initial activity&#44; number of doses used&#44; and total activity administered&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Baseline pathological characteristics&#58; the primary histological type &#40;papillary or follicular&#41;&#44; the histological subtype&#44; tumour size&#44; the presence or absence of multifocality&#44; lymph node involvement and its extent&#44; extrathyroid spread and its extent&#44; and the presence of distant metastases at diagnosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">The probability of survival was classified using the American Joint Committee on Cancer &#40;AJCC&#41;-TNM 7th edition criteria&#44; and was stratified by the risk of recurrence based on the American Thyroid Association &#40;ATA&#41; guidelines of 2009&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Recurrence&#47;persistence&#58; disease recurrence or persistence was evaluated throughout the patient follow-up period&#46; <span class="elsevierStyleItalic">Recurrence</span> was considered to have occurred if the patient presented active disease after a period of healing&#44; while <span class="elsevierStyleItalic">persistence</span> was considered to have occurred if the absence of disease could not be confirmed at any time after the initial treatment or successive treatments&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">The following possibilities were taken into consideration when the <span class="elsevierStyleItalic">final status</span> or outcome of the patients was being assessed&#58; the <span class="elsevierStyleItalic">absence of disease</span> in patients with no clinical&#44; biochemical or structural evidence of DTC based on the dynamic stratification criteria proposed by the ATA 2015<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a>&#59; and <span class="elsevierStyleItalic">persistent disease</span> in patients with persistent biochemical &#40;including indeterminate response&#41; and structural disease&#46; In patients not treated with radioiodine&#44; we used the criteria proposed by Momesso et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> &#8220;Lost to follow-up&#8221; was also considered as a final status or outcome if the initially diagnosed and treated patient did not continue active follow-up to the end of the study period&#44; in the same way as &#8220;death&#8221;&#46; In the case of death we considered two possibilities&#58; death due to DTC and death due to other causes&#46; In order to calculate follow-up time&#44; we recorded the date of death and the date of loss to follow-up&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Other aspects assessed in the study were&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">a&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Thyroglobulin antibodies</span>&#58; the investigators were asked to classify the patients according to the presence of thyroglobulin antibodies analyzed in each hospital using the usual analytical method&#46; Three qualitative categories were established&#58; negative antibodies&#44; positive antibodies with a favourable course &#40;i&#46;e&#46;&#44; decrease or negative conversion&#41;&#44; and positive antibodies with an unfavourable course &#40;persistently high or increasingly positive antibody titres&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">b&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Treatment in the context of recurrence</span>&#58; in patients with persistent&#47;recurrent disease&#44; the treatment decided in this situation was recorded &#40;surgery&#44; radioiodine&#44; radiotherapy&#44; tyrosine kinase inhibitors&#44; etc&#46;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><p id="par0085" class="elsevierStylePara elsevierViewall">Only those patients with over 90&#37; of the study variables were analyzed and included&#46;</p></li></ul></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">Results were expressed as the mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;SD&#41; for quantitative variables and as proportions for qualitative variables&#46; The Student <span class="elsevierStyleItalic">t</span>-test and analysis of variance &#40;ANOVA&#41; were used to compare quantitative variables&#46; The chi-squared test was used to compare qualitative variables&#46; The factors associated with recurrence were investigated using binary logistic regression analysis&#46; Differentiated thyroid carcinoma-specific survival was estimated using the Kaplan&#8211;Meier method&#46; The factors relating to survival were analyzed by univariate &#40;log-rank test&#41; and multivariate analyses &#40;Cox proportional hazards model&#41;&#46; Statistical significance was considered for <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46; The SPSS version 22&#46;0 statistical package &#40;IBM Corp&#46;&#41; was used throughout&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 1434 patients with DTC were included in the study&#46; Their baseline demographic and histological characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#59; no significant differences were observed between the different hospitals&#46; In the course of the study period&#44; an increase was seen in the number of cases of DTC diagnosed in both males and females&#44; particularly at the expense of papillary carcinoma&#46; The frequency of follicular carcinoma remained stable by comparison &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">In the study cohort&#44; tumour size decreased significantly during the study period&#58; the mean tumour size in 2001 was 21&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;5<span class="elsevierStyleHsp" style=""></span>mm versus 15&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;0<span class="elsevierStyleHsp" style=""></span>mm in 2015 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Likewise&#44; a significant increase was recorded &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; in the number of microcarcinomas diagnosed over the 15-year period &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; The number of patients with tumours measuring between 1 and 4<span class="elsevierStyleHsp" style=""></span>cm in size increased during the study period&#44; though not significantly so&#46; The number of tumours greater than 4<span class="elsevierStyleHsp" style=""></span>cm in size remained stable&#46; Patient age at diagnosis increased significantly&#44; from 47&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;1 years at the start to 51&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;6 years in 2015&#44; &#40;the last year of data collection&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Over 50&#37; of our patients were initially classified as being at low risk of recurrence&#46; Less than 10&#37; of the initial cohort met high risk criteria&#44; mostly due to the presence of distant metastases at diagnosis &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the results of the initial treatment provided to the study cohort&#46; The most commonly used initial treatment was total or near total thyroidectomy in over 80&#37; of the cases&#46; Hemithyroidectomy was performed in 3&#37; of the series&#44; with a tendency to increase in the course of the study period &#40;2&#46;4&#37; in 2001 versus 6&#46;9&#37; in 2015&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>ns&#41;&#46; By contrast&#44; totalizing or two-stage thyroidectomy was less frequently performed &#40;24&#37; in 2001 versus 11&#46;2&#37; in 2015&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Most of the patients &#40;83&#46;4&#37;&#41; in the cohort received radioiodine therapy after initial surgery&#46; The activity initially used&#44; the number of doses&#44; and the cumulative activity is reported in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; An initial activity of 30<span class="elsevierStyleHsp" style=""></span>mCi used in 10&#46;6&#37; of the patients was decided in patients at a low risk of recurrence in the last 5 years of the study &#40;2011&#8211;2015&#41;&#46; This activity level had not been used as the initial treatment in the previous years&#46; Over the 15 years of the study&#44; a progressive decrease was observed in the number of patients receiving radioiodine &#40;95&#46;1&#37; in 2001 versus 74&#46;1&#37; in 2015&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and in the initial mean activity used &#40;113&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>25&#46;6<span class="elsevierStyleHsp" style=""></span>mCi versus 84&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>47&#46;5<span class="elsevierStyleHsp" style=""></span>mCi&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; This decrease mainly occurred at the expense of the low-risk patients&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the radioiodine doses used according to 5-year intervals in each of the recurrence risk categories&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">A total of 409 patients &#40;29&#46;6&#37;&#41; had positive thyroglobulin antibody titres among the 1381 individuals for which this laboratory test parameter was available&#46; The majority of antibody-positive DTCs &#40;84&#46;3&#37;&#41; showed a favourable response&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">During the study period&#44; 326 patients presented disease recurrence or persistence&#44; representing 22&#46;7&#37; of the study cohort&#46; In the low-risk category 9&#46;0&#37; of the patients suffered recurrence&#44; compared with 33&#37; and 82&#37; in the intermediate- and high-risk categories&#44; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the factors independently associated with disease recurrence&#47;persistence in the study cohort&#46; Radioiodine treatment was the most commonly used initial therapy for recurrence &#40;57&#46;5&#37;&#41;&#44; followed by surgery &#40;32&#46;2&#37;&#41;&#46; In cases with advanced DTC and persistent disease&#44; external radiotherapy was used in a small percentage of cases &#40;1&#46;65&#37;&#41;&#46; Tyrosine kinase inhibitors were used in 1&#46;4&#37; of the patients&#44; and of these&#44; most were initially at high risk and with no response to other treatments&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The DTC-specific survival of the series after 15 years of follow-up was 95&#46;1&#37;&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A shows the probability of thyroid cancer survival according to the AJCC-TNM 7th edition criteria&#59; 75 patients with DTC died in the period studied&#44; 34 of them as a consequence of the thyroid tumour process &#40;2&#46;4&#37;&#41;&#46; Data referring to final clinical outcome were available for a total of 1218 patients&#59; 76&#46;2&#37; were disease-free and the remaining 23&#46;8&#37; continued to have active disease &#40;14&#37; indeterminate response&#44; 3&#46;4&#37; incomplete biochemical response&#44; and 6&#46;4&#37; incomplete structural response&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B shows the final disease status stratified according to the initial recurrence risk&#46; The percentage of patients with an excellent response proved statistically different for each of the initial risk categories &#40;84&#46;5&#37; low risk&#44; 69&#37; intermediate risk and 26&#46;6&#37; high risk&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Most of the patients with an indeterminate response were subjects with positive thyroglobulin antibodies and decreasing or stable titres&#46; At the end of follow-up this implied favourable clinical response rates of over 95&#37; in the low-risk patients and of over 85&#37; in the intermediate-risk patients&#46; The presence of persistent structural disease reached 54&#46;7&#37; in the high-risk patients versus only 1&#46;5&#37; in the low-risk subjects&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0135" class="elsevierStylePara elsevierViewall">The present retrospective study reviewed the most relevant clinical characteristics&#44; the treatments used and the final outcomes in a large cohort of patients diagnosed with DTC between 2001 and 2015 in the Autonomous Community of Castilla-La Mancha &#40;Spain&#41;&#46; The results show a population with characteristics similar to those of other Spanish national<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#8211;15</span></a> and international series&#44;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#8211;20</span></a> with a clear female predominance&#59; patients diagnosed in middle age&#59; a predominance of the papillary histological type&#59; and excellent final outcome and survival data&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The figures referring to the incidence of thyroid cancer in our Autonomous Community supplied by the population cancer registries of the provinces of Albacete&#44; Cuenca and Ciudad Real&#44; are lower than the Spanish national average&#44; with an adjusted annual incidence of 5&#46;7 cases per 100&#44;000 inhabitants for both genders in 2011&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> The retrospective data in our cohort are not findings from which epidemiological conclusions can be drawn&#44; though they indicate a significant increase in the number of cases diagnosed over the 15 years of the patient registry&#46; This increase has occurred in both women and men&#44; and at the expense of the papillary histological type&#46; In Spain&#44; the studies published on the incidence of DTC in Galicia&#44; Murcia or Navarre<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;6</span></a> all confirm the existence of an increasing incidence over more than three decades in the same groups of patients &#40;both genders and papillary carcinoma&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The exponential increase in the incidence of DTC observed in most developed countries may be related to overdiagnosis&#44; among other factors&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> The use of different and increasingly sophisticated imaging techniques accessible to a population<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> demanding greater healthcare undoubtedly facilitates the diagnosis of small and possibly nonlethal lesions&#44; which in past decades would not have become diagnostic or treatment problems&#46; Despite the limitations of the study&#44; some of our findings&#44; such as the exponential increase in microcarcinomas and the significant decrease in tumour size over the study period&#44; suggest that improvements in diagnostic procedures and histopathological study criteria may have contributed to an increase in the number of patients with incidental lesions in Castilla-La Mancha&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">On the other hand&#44; it is not possible to discard the existence of other potential factors that may be contributing to an increase in thyroid cell carcinogenesis &#40;ionizing radiation&#44; nuclear medicine or diagnostic procedures&#44; still unidentified environmental carcinogens&#44; etc&#46;&#41;&#44; and which could explain the increase in larger tumours described in some series&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;23</span></a> In our study&#44; the percentages of tumours measuring 1&#8211;4<span class="elsevierStyleHsp" style=""></span>cm in size and larger lesions &#40;&#62;4<span class="elsevierStyleHsp" style=""></span>cm&#41; remained stable during the data collection interval&#44; though in absolute terms the number of patients with tumours between 1 and 4<span class="elsevierStyleHsp" style=""></span>cm in size also experienced a significant increase&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The clinical guides published in recent years<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;9&#44;16</span></a> were developed to facilitate the best clinical and therapeutic decisions&#44; based on scientific evidence&#44; with the primary aim of minimizing the potential damage of overtreatment in a majority of patients at low risk of mortality&#44; and of individualizing treatment in patients with high-risk DTC&#46; In general&#44; the most recent guides reflect a clear preference for more conservative management both in relation to surgery and the use of radioiodine&#46; In some already published series&#44; the final outcomes in patients with DTC treated according to the evidence-based international guidelines are better than the outcomes before such guidelines were implemented in clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> In Italy&#44; a recent retrospective study<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> attempted to assess how publication of the 2009 ATA guidelines<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> has modified the clinical practice of Italian endocrinologists in patients with DTC&#46; Our results are consistent with those of the Italian study&#44; which reflect few changes in surgical treatment&#46; Most of the patients in our cohort underwent total or intentionally total thyroidectomy&#44; regardless of the baseline clinical characteristics&#46; Although we found a greater use of hemithyroidectomy as initial treatment&#44; this technique remains a minority surgical option&#44; and possibly reflects a lesser indication of totalized thyroidectomy when the final pathology report diagnoses incidental carcinoma&#46; However&#44; with regard to treatment with radioactive iodine&#44; we confirmed a lesser use&#44; particularly from 2010 onwards&#44; and especially in low-risk patients&#46; This would suggest that the use of this treatment modality is adapted to the recurrence risk category in Castilla-La Mancha&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">26&#44;27</span></a> Lamartina et al&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> reported radioiodine to be used between 2013 and 2016 in 41&#46;2&#37; of low-risk patients&#44; 87&#46;1&#37; of intermediate-risk patients and 93&#46;1&#37; of high-risk patients&#46; Likewise&#44; the radioiodine activity administered to low-risk patients was significantly lower than in high- and intermediate-risk patients in both the Italian study and in our own series&#46; In a recent study&#44; the use of low doses of radioactive iodine in low-risk patients followed-up on in hospitals in Castilla-La Mancha afforded excellent results in most of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The recurrence risk classification proposed by the ATA in its 2009 guidelines<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> has consistently shown its usefulness in discriminating the higher risk population&#44; allowing for the individualization of treatment both initially and in the immediate follow-up period after surgery&#46; This classification uses prognostic factors that have been modified in the most recent guides<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> and which are intended to indirectly reflect tumour biology&#46; Using this stratification in our cohort&#44; over 50&#37; of the patients were classified as being at low risk&#44; with a recurrence rate of 9&#37;&#44; this being similar to the figures reported in low risk patients from other series&#44;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#44;19</span></a> though our study involved a longer clinical follow-up period&#46; Our high-risk patients showed a very high probability of recurrence &#40;over 80&#37;&#41;&#59; early identification is therefore essential for individualized management adapted to the risk posed by this type of tumour&#46; We consider that our results validate the risk classification criteria proposed by the international guides in a large series of patients with DTC in Spain&#46; Initial patient stratification&#44; even in the case of tumours with an excellent prognosis a priori&#44; is a key element in the therapeutic orientation of patients with DTC&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The overall disease recurrence&#47;persistence rate &#40;approximately 22&#37;&#41; and the related factors &#40;gender&#44; tumour size and tumour spread&#41; are similar to those of other cohorts&#46; The presence of positive thyroglobulin antibody titres with an unfavourable course is an independent factor for recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> This poor prognosis factor was not analyzed in many DTC series&#44; and was found to be an unfavourable factor for both recurrence and survival in our series&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The survival outcomes of patients with DTC in Castilla-La Mancha are excellent&#44; the factors associated with a poorer prognosis being patients with extensive extrathyroid involvement&#44; distant metastatic spread&#44; age at diagnosis &#62;55 years&#44; and the presence of antithyroglobulin antibody titres with an unfavourable course&#46; With the exception of the presence of thyroid autoimmunity&#44; these factors are consistent with those considered in the AJCC classification&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> The DTC-specific mortality rate in our cohort was low&#46; Based on the results of our study&#44; we cannot know whether the mortality rate has remained stable or whether it has increased because of the increase in diagnosis&#46; However&#44; the retrospective epidemiological data found in the registries of Castilla-La Mancha indicate that up until 2010 the annual standardized thyroid cancer mortality rate for both genders remained stable or decreased &#40;0&#46;8 cases per 100&#44;000 in 2000 versus 0&#46;5 per 100&#44;000 in 2010&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Most published studies on treatment response and final outcome in series of patients with DTC have been conducted in patient populations subjected to surgery and radioiodine ablation&#46; In the data of the Castilla-La Mancha series referring to treatment response and final outcome&#44; use was made of the dynamic stratification criteria proposed by Tuttle for patients treated with surgery and radioiodine&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;19</span></a> and the response criteria for low-risk patients subjected to thyroidectomy without radioiodine or to hemithyroidectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> The excellent response percentages in the three categories were similar to those described in the ATA guide of 2015&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> which envisages percentages between 86 and 91&#37; for low-risk patients&#44; 57&#8211;63&#37; for intermediate-risk patients&#44; and 14&#8211;16&#37; for high-risk patients&#46; The inclusion of lower-risk patients not treated with radioiodine&#44; prolonged patient follow-up&#44; and the analysis of outcomes after the treatment of disease relapses may possibly have improved the final outcomes&#44; particularly in intermediate- and high-risk patients &#40;with excellent responses in 69&#37; and 26&#46;6&#37;&#41;&#46; The dynamic stratification criteria for assessing final outcome in our cohort reproduce the data found in other international series&#44; and should be used on a routine basis to analyze treatment response and final outcomes in patients diagnosed with DTC&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Our study has the limitations inherent in retrospective data collection over a long period of time &#40;2001&#8211;2015&#41; and in different hospitals&#46; However&#44; a large number of patients were included from almost all hospitals in Castilla-La Mancha&#44; and moreover we only analyzed those patients with a very high percentage of satisfactorily collected study variables&#46; This allows us to confirm that the characteristics of our cohort were similar to those of other Spanish national series&#44; and that in addition to the increase in the number of diagnosed cases&#44; the final outcomes in terms of survival and healing of the disease &#8211; using the updated response and dynamic stratification criteria &#8211; were excellent&#46; Lastly&#44; the data obtained in our study suggest that the trends in the management approach to patients with DTC &#40;particularly as regards radioiodine treatment&#41; are changing in concordance with the latest international recommendations&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest in relation to the present study&#46;</p></span></span>"
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            0 => "Carcinoma diferenciado de tiroides"
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            2 => "Espa&#241;a"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The CADIT-CAM study was designed to retrospectively analyze the clinical characteristics&#44; treatments&#44; and outcomes of patients with differentiated thyroid carcinoma &#40;DTC&#41; in Castilla La Mancha&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A total of 1434 patients from 7 hospitals in Castilla La Mancha were enrolled into the study from 2001 to 2015&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Seventy-seven percent of patients were female&#44; with a mean age at diagnosis of 48 years&#46; Papillary thyroid carcinoma accounted for 93&#37; of cases&#46; Mean tumor size was significantly smaller at final follow-up &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Radioiodine ablation &#40;RA&#41; was performed in 84&#37; of patients&#44; and its use decreased during the study&#44; especially in tumors with low recurrence risk&#46; Recurrence occurred in 22&#37; of patients and was associated to male gender&#44; greater tumor size&#44; multifocality&#44; lymph node metastases&#44; extrathyroid involvement&#44; distant metastases and increasing thyroglobulin antibody titers&#46; At the end of follow-up 76&#46;2&#37; of patients were alive and free of disease&#44; 2&#46;4&#37; had died from DTC&#46; Overall survival of the cohort was 95&#46;1&#37; at 15 years of follow-up&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Characteristics of DTC in this Spanish cohort are similar to those reported in other studies in our country&#46; Final results were excellent and use of treatment &#40;RA&#41; was consistent with risk-stratified recommendations&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El estudio CADIT-CAM es un estudio retrospectivo dise&#241;ado para analizar las caracter&#237;sticas cl&#237;nicas&#44; el tratamiento y los resultados finales de los pacientes con c&#225;ncer diferenciado de tiroides &#40;CDT&#41; en Castilla-La Mancha&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se ha incluido a 1&#46;434 pacientes diagnosticados en 7 hospitales castellano-manchegos&#44; entre 2001 y 2015&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El 77&#37; eran mujeres&#44; con una edad media al diagn&#243;stico de 48 a&#241;os&#44; y el tipo histol&#243;gico principal fue carcinoma papilar en el 93&#37;&#46; El tama&#241;o el tumor fue descendiendo de forma significativa a lo largo de los 15 a&#241;os &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; El tratamiento con radioyodo se ha utilizado en el 84&#37; de la serie&#44; habiendo disminuido su utilizaci&#243;n a lo largo del estudio&#44; sobre todo en los de bajo riesgo de recurrencia&#46; Existi&#243; recurrencia en el 22&#37; de los pacientes&#44; siendo los factores relacionados con la misma&#58; sexo masculino&#44; mayor tama&#241;o tumoral&#44; multifocalidad&#44; presencia de met&#225;stasis linf&#225;ticas o a distancia o de afectaci&#243;n extratiroidea as&#237; como la presencia de anticuerpos antitiroglobulina con evoluci&#243;n desfavorable&#46; Al final del seguimiento&#44; el 76&#44;2&#37; de los casos estaban libres de enfermedad y el 2&#44;4&#37; de los pacientes hab&#237;an fallecido por CDT&#44; siendo la supervivencia global de la cohorte del 95&#44;1&#37; a los 15 a&#241;os de seguimiento&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las caracter&#237;sticas del CDT de la cohorte de Castilla-La Mancha son similares a las de otras series espa&#241;olas&#46; Los resultados finales son excelentes y las tendencias del tratamiento se han ido adaptando al riesgo de recurrencia de los pacientes&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Sastre Marcos J&#44; Aznar S&#44; &#193;lvarez V&#44; Torres B&#44; Delgado M&#44; Gonz&#225;lez J&#44; et al&#46; Resultados del seguimiento de pacientes con carcinoma diferenciado de tiroides en Castilla-La Mancha &#40;2001&#8211;2015&#41;&#46; Estudio CADIT-CAM&#46; Endocrinol Diabetes Nutr&#46; 2019&#59;66&#58;164&#8211;172&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">The names of the researchers participating in the CADIT-CAM study group are related in <a class="elsevierStyleCrossRef" href="#sec0035">Appendix 1</a>&#46;</p>"
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            "apendice" => "<p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Complejo Hospitalario Universitario de Albacete</span>&#58; J&#46;J&#46; Alfaro&#44; C&#46; Lamas&#44; F&#46; Botella&#44; C&#46; Gonzalvo&#44; A&#46; Hern&#225;ndez&#44; L&#46;M&#46; L&#243;pez&#44; L&#46; Garc&#237;a&#44; P&#46; Pin&#233;s&#44; R&#46; Qu&#237;lez&#46; <span class="elsevierStyleItalic">Hospital Virgen de la Luz&#44; Cuenca</span>&#58; M&#46; Alramad&#225;n&#44; D&#46; Mart&#237;n&#44; D&#46; Calder&#243;n&#44; J&#46; P&#233;rez Rodr&#237;guez&#44; F&#46; Jim&#233;nez&#46; <span class="elsevierStyleItalic">Hospital Universitario de Guadalajara</span>&#58; S&#46; Herranz&#46; <span class="elsevierStyleItalic">Hospital General de Ciudad Real&#58;</span> M&#46; Aguirre&#44; P&#46; G&#243;mez&#44; J&#46; Moreno&#46; <span class="elsevierStyleItalic">Complejo Hospitalario Mancha Centro&#44; Alc&#225;zar de San Juan</span>&#58; A&#46; Garc&#237;a-Manzanares&#44; I&#46; G&#243;mez&#44; J&#46; Silva&#44; F&#46; del Val&#46; <span class="elsevierStyleItalic">Hospital Nuestra Se&#241;ora del Prado&#44; Talavera de la Reina</span>&#58; B&#46; Blanco&#44; P&#46; de Diego&#44; M&#46;G&#46; Llaro&#44; D&#46; Ariadel&#46; <span class="elsevierStyleItalic">Complejo Hospitalario de Toledo</span>&#58; E&#46; Castro&#44; I&#46; Luque&#44; E&#46; Maqueda&#44; A&#46; Marco&#44; A&#46; Mart&#237;nez&#44; A&#46; Vicente&#44; M&#46;A&#46; Carrasco&#44; J&#46; L&#243;pez&#46;</p>"
            "etiqueta" => "Appendix 1"
            "titulo" => "Investigators participating in the CADIT-CAM study group"
            "identificador" => "sec0035"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Number of patients diagnosed by 5-year intervals according to histological type&#44; gender and tumour size&#46; &#40;A&#41; Number of patients diagnosed according to primary histological type and gender&#46; &#40;B&#41; Number of patients diagnosed in each 5-year interval according to tumour size&#46; Microcarcinomas &#40;tumours<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm&#41; were the group that increased significantly &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; over the study period&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Radioiodine treatment according to risk categories by 5-year intervals in patients with DTC in the Castilla-La Mancha cohort&#46; The figure shows the percentages of patients receiving at least one radioiodine dose in each recurrence risk category &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; The mean activities used in each risk category and by 5-year interval are indicated&#46; Statistically significant differences were found in the low-risk &#40;&#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and intermediate-risk patients &#40;&#42;&#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; There were no differences in the high-risk patients&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Differentiated thyroid carcinoma-specific survival plot and final clinical outcomes in the cohort of patients in Castilla-La Mancha&#46; &#40;A&#41; Specific survival &#40;Kaplan&#8211;Meier&#41; is represented by AJCC 7th edition stages&#44; showing a significant difference between the different stages &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; &#40;B&#41; Final outcome of the patients according to initial recurrence risk category&#46; The dynamic stratification criteria have been used&#46; The percentage of patients with an excellent response was statistically different for each of the baseline risk categories &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mean age at diagnosis &#40;years&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&#46;30<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mean follow-up &#40;years&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Primary histological type&#58; papillary</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">92&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Papillary histological subtype</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Classical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Microcarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Follicular variant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Multifocality</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Lymph node involvement</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Central<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Extrathyroid involvement</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Minimal extrathyroid extension<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Distant metastases</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Recurrence risk classification</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intermediate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Demographic and initial presentation characteristics of the cohort of patients with DTC in Castilla-La Mancha&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Quantitative variables were reported as the mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;SD&#41;&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">I-131&#58; radioiodine&#46;</p>"
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                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="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial surgical treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total thyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Two-stage total thyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Subtotal thyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hemithyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Not operated upon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Lymphadenectomy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">I-131 treatment</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Initial I-131 activity &#40;mCi&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">101&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>31&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Initial I-131 activity used</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mCi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>31&#8211;100<span class="elsevierStyleHsp" style=""></span>mCi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>101&#8211;150<span class="elsevierStyleHsp" style=""></span>mCi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;150<span class="elsevierStyleHsp" style=""></span>mCi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Number of I-131 doses</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>One dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>More than one dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Cumulative I-131 activity</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60;300<span class="elsevierStyleHsp" style=""></span>mCi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>300&#8211;600<span class="elsevierStyleHsp" style=""></span>mCi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;600<span class="elsevierStyleHsp" style=""></span>mCi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;2&#37;&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="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recurrence &#40;variables&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;15&#8211;2&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tumour size<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;23&#8211;2&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multifocality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;59&#8211;3&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cervical adenopathies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;7&#8211;6&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Extrathyroid involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;4&#8211;3&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Positive thyroglobulin antibodies with poor course&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Binary logistic regression analysis</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival &#40;variables&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95&#37;CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">p</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="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age at diagnosis<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>55 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;84&#8211;22&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Extrathyroid involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;6&#8211;55&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Distant metastases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;18&#8211;23&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Positive thyroglobulin antibodies with poor course&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;35&#8211;19&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Cox regression analysis</span></td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Factors independently related to recurrence&#47;persistence and survival in the DTC cohort of Castilla-La Mancha&#46;</p>"
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Article information
ISSN: 25300180
Original language: English
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2022 February 15 8 23
2022 January 15 4 19
2021 December 16 9 25
2021 November 17 7 24
2021 October 12 9 21
2021 September 14 7 21
2021 August 15 7 22
2021 July 12 9 21
2021 June 15 5 20
2021 May 25 12 37
2021 April 23 18 41
2021 March 19 4 23
2021 February 6 6 12
2021 January 16 9 25
2020 December 16 7 23
2020 November 19 11 30
2020 October 14 5 19
2020 September 14 10 24
2020 August 13 5 18
2020 July 19 8 27
2020 June 14 0 14
2020 May 18 8 26
2020 April 11 3 14
2020 March 13 1 14
2020 February 14 3 17
2020 January 16 5 21
2019 December 11 6 17
2019 November 9 2 11
2019 October 11 2 13
2019 September 10 9 19
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos