Preoperative lymphoscintigraphy and tumor histologic grade are associated with surgical detection of the sentinel lymph node

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B) Nódulo con cambio de ecogenicidad tras la inyección intratumoral del radioisótopo. C) Marcaje con radioisótopo de microcalcificaciones con un marcador metálico interno, guiado por estereotaxia. D) Linfogammagrafía (proyección anterior) con enmascaramiento y ganglio centinela axilar. E) Situación de la lesión mamaria y del ganglio centinela y diseño del abordaje quirúrgico. F) Sonda gammadetectora portátil modelo Europrobe®II. G) Incisión y rastreo de la axila con la sonda gammadetectora en el quirófano. H) Comprobación ex vivo con la gammasonda de la actividad de los ganglios extraídos." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Arias Ortega, M.Y. Torres Sousa, B. González García, R. Pardo García, A. González López, M. Delgado Portela" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Arias Ortega" ] 1 => array:2 [ "nombre" => "M.Y." "apellidos" => "Torres Sousa" ] 2 => array:2 [ "nombre" => "B." 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(a) Pre-chemotherapy (pre-CT) MRI: nodular enhancement (arrow) of ovoid morphology and lobular contours with heterogenous enhancement occupying the mid and posterior views of lower quadrants of left breast with luminal B HER2− immunohistochemical profile. (b) Post-CT MRI: no response to neoadjuvant therapy. The only difference is two (2) areas of central necrosis (arrow)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Cruz Ciria, F. Jiménez Aragón, C. García Mur, H. Esteban Cuesta, B. Gros Bañeres" "autores" => array:5 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Cruz Ciria" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Jiménez Aragón" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "García Mur" ] 3 => array:2 [ "nombre" => "H." "apellidos" => "Esteban Cuesta" ] 4 => array:2 [ "nombre" => "B." 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(A) Quantification of the average velocity of flow in the ascending aorta through the 2D cine PCA modality. To the left we can see flow direction for every vessel and to the right the chart of velocity values in the cardiac cycle. (B) The same quantification was performed with 4D Flow. Note the similarity of values of the average velocity of blood measured through 2D cine PCA and 4D Flow modalities (B). (C) Selection of the ascending aorta and the pulmonary artery in one single 4D Flow study. The charts of average velocity of aorta (up) and pulmonary artery blood (down) are shown here as well. In charts A and B y-axis is blood velocity (cm/s) while x-axis is time (s). However, in chart C x-axis represents the cardiac cycle divided into sixteen (16) different phases." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.A. Pineda Zapata, J.A. Delgado de Bedout, S. Rascovsky Ramírez, C. Bustamante, S. Mesa, V.D. Calvo Betancur" "autores" => array:6 [ 0 => array:2 [ "nombre" => "J.A." "apellidos" => "Pineda Zapata" ] 1 => array:2 [ "nombre" => "J.A." "apellidos" => "Delgado de Bedout" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Rascovsky Ramírez" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Bustamante" ] 4 => array:2 [ "nombre" => "S." "apellidos" => "Mesa" ] 5 => array:2 [ "nombre" => "V.D." "apellidos" => "Calvo Betancur" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833814001301" "doi" => "10.1016/j.rx.2014.08.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0033833814001301?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510714000603?idApp=UINPBA00004N" "url" => "/21735107/0000005600000006/v1_201412120104/S2173510714000603/v1_201412120104/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Preoperative lymphoscintigraphy and tumor histologic grade are associated with surgical detection of the sentinel lymph node" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "515" "paginaFinal" => "523" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Arias Ortega, M.Y. Torres Sousa, B. González García, R. Pardo García, A. González López, M. Delgado Portela" "autores" => array:6 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Arias Ortega" "email" => array:1 [ 0 => "mariaariasortega@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.Y." "apellidos" => "Torres Sousa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "B." "apellidos" => "González García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "R." "apellidos" => "Pardo García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "González López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Delgado Portela" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital La Mancha-Centro, Alcázar de San Juan, Ciudad Real, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Cirugía General, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Obstetricia y Ginecología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La linfogammagrafía prequirúrgica y el grado histológico del tumor se asocian a la detección quirúrgica del ganglio centinela" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2407 "Ancho" => 1649 "Tamanyo" => 461139 ] ] "descripcion" => array:1 [ "en" => "(A) 99mTc-albumin nanocolloid radioisotope transportation through lead syringe. (B) Node with change in echogeneicity after intratumor injection of the radioisotope. (C) Radioisotope marking of microcalcifications through an internal stereotactic metallic marker. (D) Lymphogammagraphy (anterior projection) with masking and axillary sentinel node. (E) Location of breast lesion and sentinel lymph node and design of surgical approach. (F) Gamma-detecting portable probe model Europrobe® II. (G) Axillary incision and tracking through gamma-detecting probe at the OR. (H) Gamma-probe-guided ex vivo checking through of the activity of the extracted nodes." ] ] ] "textoCompleto" => "IntroductionMorbidity of axial lymphadenectomy is high and per se it does not increase long term survival.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> The trend toward more conservative treatments associated with an earlier diagnosis of breast cancer has decreased the incidence of affected axillay nodes and driven the search for valid alternatives to the total axillary lymphadenectomy. The selective biopsy of the sentinel lymph node (SBSN) seems to be the best option.The sentinel lymph node is the node undergoing lymphatic drainage of a tumor lesion first and directly. If unaffected the remaining nodes will not be affected either. On the contrary if it has tumor cells the risk that the remaining lymphatic nodes also contain tumor cells is high and a total regional lymphatic dissection is recommended.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The process of SBSN requires several units–Gynecology/Surgery, Radiodiagnosis, Pathological Anatomy and Nuclear Medicine working together. This fact introduces a wide array of clinical, radiological, anatomopathological or nuclear medicine variables in a process whose final goal aims at the surgical detection of the sentinel lymph node. Thus the main goal of this study is to identify which one of these variables may influence the intraoperative detection of the sentinel lymph node.Material and methodsPatientsOur sample included 210 women with histological diagnosis of breast cancer between 2005 and 2010 without clinical evidence at the image modalities of metastatic axillary adenopathies who underwent SBSN. The patients were diagnosed until 2007 and they met the inclusion and exclusion criteria established in the consensus meeting held in Salamanca in 2001<a class="elsevierStyleCrossRef" href="#bib0020">4</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>); women diagnosed between 2007 and 2010 met the modified criteria in the meeting held in Murcia, in 2006<a class="elsevierStyleCrossRef" href="#bib0025">5</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). This was a cross-sectional study in which all patients were recruited prospectively with the consent of the local ethical committee. All of them got information on their condition and the diagnostic and therapeutical proceedings they would undergo (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and all signed the corresponding informed written consents.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Process for the selective biopsy of the sentinel lymph nodeProceeding was done in our institution under the supervision of a nuclear physician trained in a validated and consolidated working team. In all cases a standard digital mammography of both breasts was performed with a mammography device Mammomat® NovationDR (Siemens AG, Medical Solutions, Erlangen, Germany). The study consisted of two (2) projections (cranial-caudal and mi-lateral oblique), additional projections when necessary and one ultrasound study of both breasts and armpits with an ultrasound device Sonoline® Antares™ (Siemens AG, Medical Solutions, Erlangen, Germany). All breast lesions visible through ultrasound were thick needle biopsied (TNB) while those identifiable only through mammography were biopsied through a stererotactic vacuum assisted system (VAS) on a prone table. Nodes suspicious of metastasis were histologically analyzed after an ultrasound-guided TNB. All biopsies and the eco-guided injection of radioisotopes were performed by the same operator.The tracer was injected the day before the surgical intervention (two-day protocol). As the radioisotope the 99mTc-albumin nanocolloid was used carried in a syringe protected by a led capsule (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). When the administration route was deep (peri or intratumoral) the 1–3mCi dose was used (37–111MBq) in a dilution volume of de 1–3ml and in an injection volume of 0.2–0.4ml. When the administration route was superficial (intradermic periareolar), the dose was 0.5–1mCi (18.5–37MBq) in an injection volume of 0.2ml. In patients with non-palpable breast cancer the radiotracer was injected inside the tumor by the Radiodiagnosis Unit with an ultrasound or stereotactic guide (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). When the tumor was palpable the injection was peritumoral and administered at the Unit of Nuclear Medicine. When the sentinel lymph node was not found at the lympho-gammagraphy the tracer was injected back again in a periareolar intradermic location.All patients underwent presurgical gammagraphy in the Unit of Nuclear Medicine the same day of the radioisotope injection. Even though the gammagraphy can be done the same day of the radioisotope injection or 24h later we decided to perform the gammagraphy on the same day to avoid underestimation of the number of sentinel lymph nodes or asynchronous uptake of different sentinel lymph nodes. Images were early acquired at 30min, and lately at 2 and 4h. When breast lesions were found near the armpit the images were processed through some sort of “masking” by placing a device made out of led in the injection zone so that the nonmigrated signal would not interfere with the identification of the sentinel lymph nodes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). After identifying the sentinel lymph nodes in the lympho-gammagraphy we proceeded to cutaneous positioning. The unidentification of the sentinel lymph nodes at the gammagraphy was not an exclusion cause for the patient.In the OR the type of incision and the approach were chosen both based on the tumor and breast size and its location (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). With the help of one gamma-detecting probe the sentinel lymph node and the non-palpable tumors could be found (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Sentinel lymph node was said to have a greater number of counts. If activity shown was ≥10% of maximum activity secondary sentinel lymph nodes were looked for and found (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The SBSN intervention with axillary digital exploration was concluded.The pathological examination of both the sentinel lymph node and the nodes obtained in the axillary lymphadenectomy was deferred in 176 patients and performed intraoperatively in the last 34 patients because since 2010 the Anatomical Pathological Section uses one R-100i analyzer allowing us to perform the One Step Acid Nucleic Amplification (OSNA®) molecular biological analysis intraoperatively. The nodes that were studied in a deferred way were processed with hematoxiline–eosine and if results were negative for malignancy one immunohistochemical study was performed too. When this immunohistochemical study was positive the diagnosis was metastasis; if negative the conclusion was that the sentinel lymph node was negative. In the histopathological study macrometastases were tumor deposits >2mm, micrometastases were tumor deposits between 0.2 and 2mm while foci <0.2mm were said to be isolated tumor cells. For the nodes studied intraoperatively through the R-100i analyzer, “++” was considered macrometastasis, “+” micrometastasis, and “−” absence of metastasis, isolated cells or pollution.Data mining and statistical analysisFor the descriptive analysis data were gathered on age, palpation, radiological presentation, breast density, location of lesion in the breast–lesions located in the junction of quadrants were considered to be located clockwise in the second quadrant, the injection route of radioisotope, the detection of the sentinel lymph node in the lympo-gammagraphy, the detection of the sentinel lymph node at the OR, the tumor size, the degree of histological differentiation and the number of axillary relapses (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Data were gathered prospectively by an independent investigator in a table of variables and analyzed with the statistical program SPSS® v.15.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>In an effort to study the variables associated with the surgical detection of the sentinel lymph node a logistic regression analysis was performed with overall data on the sample (210 patients). After a review of the available medical literatura<a class="elsevierStyleCrossRefs" href="#bib0030">6–16</a> we chose both the most relevant variables and those that might be associated. In our multivariate logistic regression model were tagged as a dependent variable the surgical detection of the sentinel lymph node and as independent variables the radiological presentation, the radiological density, the location of the lesion, the route of the injection of the radioisotope, the detection of the sentinel lymph node in the lympo-gammagraphy, the size of lesion, the histological lineage and the degree of histological differentiation of lesion.Simple logistic regressions were performed for every independent variable. The less significant variables were eliminated from the major model one by one until obtaining an abridged model including variables with p<0.15 only. The interactions among variables included in our abridged model were assessed together with the test of ratio of verisimilitude. One multivariate model with variables showing influence was performed and the predictive ability of the model by studying through the area under the receiver operating characteristic (ROC) curve, the odds ratio (OR) and the confidence interval at 95% (95% CI) were estimated for these variables.ResultsDescriptive analysisThe average age of patients was 54 years old with-ranging between 25 and 87 years old. In 48.1% of patients breast density was intermediate. The most widely used injection route of the radioisotope was the isolated deep one (72.7%). Most lesions were palpable (57.1%), presenting as nodes (67.1%), <2cm (64.8%), localized in the supero-external quadrant (49.1%) and usually ductal carcinomas (85.7%) with infiltration (66.2) and grade II in histological differentiation (44.8%) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The sentinel lymph node was found in 97.6% of preoperative gammagraphies while at the OR it was found in 95.7% of patients. During the follow-up of patients axillary relapse could be found (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).Multivariate logistics regression analysisData from the final model showed that when the sentinel lymph node was detected in the lympho-gammagraphy the OR was 50.28 (95% CI: 6.107–414.966). When it comes to lesions with histological differentiation grade II the OR was 0.577 (95% IC: 0.077–4.343), for grade III the OR was 0.224 (95% IC: 0.03–1.655). The test of ratio of verisimilitude showed that the variables eliminated did not add any additional information to the model. There were no atypical values capable of altering our results. The area under the curve showed a prediction percentage of our model of 0.75 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>DiscussionIn our study we tried to show that the surgical detection of the sentinel lymph node is significantly associated with the prior gammagraphic detection of the sentinel lymph node and the degree of histological differentiation of the tumor.The limitation in the access to this modality can be due to the fact that some studies analyzed the utility of lympho-gammagraphy inside the process of SBSN. However according to our results patients whose sentinel lymph node/s has/have are detected through the lympho-gammagraphy (in equal conditions to other variables) have a 50.280 times greater probability for the node/s to also be surgically detected than patients whose tests were negative. Gammagraphy is useful in patients with a history of interventions in order to show the absence of the sentinel lymph node but also to detect sentinel lymph nodes of atypical localization.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Some studies recommend gammagraphies since they can assess the axillary status and predict the number of sentinel lymph nodes to be extracted–even the node/s histological status.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> Also to prevent further complications due to lack of diffusion of the radiotracer or spreading to atypical locations.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> However for some authors it does not improve the surgical detection of the sentinel lymph node.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> It has been said that gammagraphy is also effective to assess the status of sentinel lymph nodes and that their negative or positive result can be associated with the number of sentinel lymph nodes surgically removed.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> The same way there are studies that indicate that the SBSN modality can be developed in hospitals without nuclear medicine since such modality does not imply greater survival recurrence or reduction in patients.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> As a matter of fact the unidentification of the sentinel lymph node in the lympho-gammagraphy should not be an exclusion criterion for the SBSN modality. In any case our results recommend to keep on performing sentinel lymph node detection gammagraphies before the surgical gammagraphies.For Krausz et al.,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> the tumor grade was the only significant variable: the higher the grade the more aggressive the tumor is and the higher the likelihood of node metastasis. This is consistent with our results that indicate one direct association between the tumor grade and the likelihood of failure in the detection of the sentinel lymph node at the OR. In this sense some studies indicate that the in situ ductal carcinoma, the low likelihood of axillar metastasis should lead us to resect the tumor without performing SBSN which would only be used for cases in which in situ ductal carcinoma is a palpable mass showing extensive microcalcifications or when being multicentric.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Our study shows that one grade II patient–all other variables being equal is 0.6 times more likely to have the sentinel lymph node detected surgically than when we are talking about a grade I patient. On the other hand in a grade III lesion–all other variables being equal the likelihood is 0.2 lower than in a grade I lesion. High grade-tumors have a greater tendency to metastazise in axillary nodes, increase the number of false negatives, reduce the negative predictive value of SBSN and increase the number of axillary recurrences.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> The most common cause to prevent tracer migration is metastatic axillary blockade. This can explain why the histologic tumor grade is associated with the surgical detection of the sentinel lymph node since the proportion of positive axillary nodes is greater in patients who do not show any tracer migrations.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> Even though this can lead us to perform one axillary lymphadenectomy when the sentinel lymph node is not detected in the lymphogammagraphy our attitude should not be excluding the SBSN even after late sequences and the reinjection of radioisotopes due to the probability of surgical detection through the gamma-detecting probe. This is especially important in nodes whose location in the armpit makes it hard to detect them through the gammacamera.There is a great methodological disparity in the SBSN yet the results we got are similar to the ones published and generally accepted as optimal results by most authors.<a class="elsevierStyleCrossRefs" href="#bib0105">21–27</a> The ROC area under the curve obtained shows an optimal discrimination of our model to be able to predict in what patients the sentinel lymph node will be detected in the OR and in what patients; by the way we have not found any similar studies on this regard. In the associative model we included another six (6) variables controversial on former studies without the surgical detection of the sentinel lymph node being significant. We have not found any recent studies on the relation between the radiological presentation of the tumor and the surgical detection of the sentinel lymph node. In our study the relation with any forms of presentation has not been significant probably because the surgical detection of the sentinel lymph node is based on the degree of infiltration and the histological grade rather than the form of presentation of image studies. In other studies it was observed that there was a statistically significant relation between the body mass index (BMI) and the non-detection of the sentinel lymph node in the lympho-gammagraphy maybe because in the fatty breasts there is an insufficient lymphatic network to be able to transfer the tracer.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> Our study did not replicate this association probably because there is not always a correlation between a greater BMI and a greater quantity of breast fat. Similarly for some authors the probability of surgically detecting the sentinel lymph node is greater in tumors located at the superior-external quadrant of the breast than in those found at the infero-internal quadrant.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Nevertheless the location of the tumor at the supero-external quadrant can make the non-migrated radioisotope signal interfere with that of the sentinel lymph node. In our study no quadrants showed a significant relation with the surgical detection of the sentinel lymph node maybe because the tracer migration was forced through superficial route in cases where it could not be detected in the lympho-gammagraphy–with masking if necessary, because the sentinel lymph nodes were signaled and their identification facilitated at the OR. When it comes to the possible combinations of the injection of the 99mTc radioisotope–through superficial or deep route and with the association (or not) of colorants several studies have analyzed its relation with technical efficacy<a class="elsevierStyleCrossRefs" href="#bib0035">7,12–14,29–31</a> while showing that the sentinel lymph node is usually associated with the superficial route. In our study nor the isolated deep injection or the deep injection with superficial injection of the marker 99mTc have been closely associated with the surgical detection of the sentinel lymph node probably because we always force migration through one superficial injection if the deep injection has not given any results in the previous lymphography. Tumor size increases the number of sentinel lymph nodes extracted through SBSN<a class="elsevierStyleCrossRef" href="#bib0030">6</a> as well as the likelihood that other non-sentinel lymph nodes are affected.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> As a matter of fact in non-palpable lesions the efficacy of the technique is lower than in palpable ones.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> Some authors claim that the bigger the tumor size the lower the detection rate.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> For other authors however tumor size is not a determining factor<a class="elsevierStyleCrossRef" href="#bib0080">16</a> which is consistent with our results. We have not found former published studies analyzing the relation between the histological lineage of tumor lesion and the surgical detection of the sentinel lymph node and our results have not shown a significant relation either.Our study is limited by the sample size number which does not allow us to have the recommended number of patients in each subcategory and is also limited by the great variability of methods used in each institution which in turn does not allow us to perform a reliable comparison of results. Our findings should be confirmed in future studies with larger samples yet for the time being we believe it is very convenient to keep on performing preoperative lympho-gammagraphies.In sum both the preoperative lympho-gammagraphy and the histologic tumor grade influence on the surgical detection of the sentinel lymph node in such a way that patents with high histologic tumor grades or those whose sentinel lymph node/s has/have not be detected in the preoperative lympho-gammagraphy there is a greater probability of not detecting it during the intervention either.Ethical responsibilitiesProtection of people and animalsAuthors confirm that no experiments have been performed on human beings or animals.Data confidentialityAuthors confirm that the protocols of their centers have been followed on matters concerning the publishing of data from patients. They also confirm that all patients included in this study have been given enough information and handed over their written informed consent for their participation in this study.Right to privacy and informed consentAuthors confirm that in this report there are no personal data of patients.Authors<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1Manager of the integrity of the study: MAO and MYTS.</li><li class="elsevierStyleListItem" id="lsti0010">2Original idea of the study: MAO and MYTS.</li><li class="elsevierStyleListItem" id="lsti0015">3Study design: MAO and MYTS.</li><li class="elsevierStyleListItem" id="lsti0020">4Data mining: MAO, MYTS, BGG, RPG, AGL and MDP.</li><li class="elsevierStyleListItem" id="lsti0025">5Data analysis and interpretation: MAO, MYTS, BGG, RPG, AGL and MDP.</li><li class="elsevierStyleListItem" id="lsti0030">6Statistical analysis: MAO and MYTS.</li><li class="elsevierStyleListItem" id="lsti0035">7Reference search: MAO, MYTS and BGG.</li><li class="elsevierStyleListItem" id="lsti0040">8Writing: MAO, MYTS, BGG, RPG, AGL and MDP.</li><li class="elsevierStyleListItem" id="lsti0045">9Manuscript critical review with intellectually relevant contributions: SCC MAO, MYTS, BGG, RPG, AGL and MDP.</li><li class="elsevierStyleListItem" id="lsti0050">10Final version approval: MAO, MYTS, BGG, RPG, AGL and MDP.</li></ul>Conflict of interestsThe authors reported no conflicts of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres389409" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Material and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec367699" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres389410" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec367698" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Process for the selective biopsy of the sentinel lymph node" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Data mining and statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Descriptive analysis" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Multivariate logistics regression analysis" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0050" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Authors" ] 10 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-08-05" "fechaAceptado" => "2012-11-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec367699" "palabras" => array:4 [ 0 => "Sentinel node biopsy" 1 => "Breast cancer" 2 => "Surgery" 3 => "Nuclear imaging" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec367698" "palabras" => array:4 [ 0 => "Biopsia del ganglio centinela" 1 => "Cáncer de mama" 2 => "Cirugía" 3 => "Imagen nuclear" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo study which variables involved in the process of selective sentinel node biopsy (SSNB) influence the intraoperative detection of the sentinel lymph node. Material and methodsThis was a prospective cross-sectional study in 210 patients (mean age, 54 years) diagnosed with breast cancer who underwent SSNB. We recorded clinical, radiological, radioisotope administration, surgical, and histological data as well as follow-up data. We did a descriptive analysis of the data and an associative analysis using multivariable regression. ResultsDeep injection alone was the most common route of radioisotope administration (72.7%). Most lesions were palpable (57.1%), presented as nodules (67.1%), measured less than 2cm in diameter (64.8%), were located in the upper outer quadrant (49.1%), were ductal carcinomas (85.7%), were accompanied by infiltration (66.2%), and had a histologic grade of differentiation of II (44.8%). Preoperative scintigraphy detected the sentinel node in 97.6% of cases and 95.7% were detected during the operation. One axillary relapse was observed. In the associative study, the variables “preoperative lymphoscintigraphy” and “histologic grade of differentiation of the tumor” were significantly associated with the detection of the sentinel lymph node during the operation. ConclusionThe probability of not detecting the sentinel lymph node during the surgical intervention is higher in patients with high histologic grade tumors or in patients in whom preoperative lymphoscintigraphy failed to detect the sentinel node." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivoEstudiar qué variables implicadas en el proceso de la biopsia selectiva del ganglio centinela (BSGC) influyen en la detección intraoperatoria del ganglio centinela. Material y métodosEstudio transversal prospectivo de 210 pacientes (edad media: 54 años) diagnosticadas de cáncer de mama a las que se les realizó BSGC. Se recogieron los datos clínicos y radiológicos, de la administración del radioisótopo, quirúrgicos, de anatomía patológica y de seguimiento, y se realizó un análisis descriptivo y asociativo mediante una regresión múltiple multivariante. ResultadosLa vía de inyección del radioisótopo más utilizada fue la profunda aislada (72,7%). La mayoría de las lesiones fueron palpables (57,1%), se presentaron como nódulos (67,1%), fueron menores de 2cm (64,8%), se localizaron en el cuadrante supero-externo (49,1%), se trataba de carcinomas ductales (85,7%), con infiltración (66,2%) y el grado de diferenciación histológica fue II (44,8%). Con la gammagrafía prequirúrgica se detectó el ganglio centinela en el 97,6% de los casos, y en el quirófano el 95,7%. Se observó una recurrencia axilar. En el estudio asociativo, las variables «linfogammagrafía prequirúrgica» y «grado de diferenciación histológica del tumor» mostraron una asociación estadísticamente significativa con la detección del ganglio centinela en el quirófano. ConclusiónLa probabilidad de no detectar el ganglio centinela durante la intervención quirúrgica es mayor en los pacientes con tumores de alto grado histológico o en las que no se ha conseguido verlo en la linfogammagrafía prequirúrgica." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Arias Ortega M, Torres Sousa MY, González García B, Pardo García R, González López A, Delgado Portela M. La linfogammagrafía prequirúrgica y el grado histológico del tumor se asocian a la detección quirúrgica del ganglio centinela. Radiología. 2014;56:515–523." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2407 "Ancho" => 1649 "Tamanyo" => 461139 ] ] "descripcion" => array:1 [ "en" => "(A) 99mTc-albumin nanocolloid radioisotope transportation through lead syringe. (B) Node with change in echogeneicity after intratumor injection of the radioisotope. (C) Radioisotope marking of microcalcifications through an internal stereotactic metallic marker. (D) Lymphogammagraphy (anterior projection) with masking and axillary sentinel node. (E) Location of breast lesion and sentinel lymph node and design of surgical approach. (F) Gamma-detecting portable probe model Europrobe® II. (G) Axillary incision and tracking through gamma-detecting probe at the OR. (H) Gamma-probe-guided ex vivo checking through of the activity of the extracted nodes." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1520 "Ancho" => 1473 "Tamanyo" => 92255 ] ] "descripcion" => array:1 [ "en" => "Receiver operating characteristic (ROC) area under the curve." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => 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"><td 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" style="border-bottom: 2px solid black">Inclusion criteria \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Exclusion criteria \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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. No evidence of clinical axillary or ultrasound (N0) \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. Non-acceptance from the patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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. Invasive tumors with a major diameter<3cm (T1, T2) \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. Breast cancer T3 and T4 and inflammatory (stages of high probability of axillary affectation being the search for the sentinel lymph node not a priority) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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. Intraductal tumors: (a) if mastectomy is indicated; (b) high nuclear grade and/or comedocian; (c) suspicion of microinvasion; and (d) extensive (>5cm) \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. Multicentric lesions (due to the existence of several foci independent from the primary tumor each one of which can have a different lymphatic drainage route which in turn can increase the rate of false negatives) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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. Multifocal breast cancer when the biggest lesion size was <3cm \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. Axillary affectation (N1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">5. Presence of distance metastasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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. Pregnant or breastfeeding women (in these patients the use of radioactive material is not indicated) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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. Surgery or prior axially radiotherapy \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab599933.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Inclusion and exclusion criteria of patients until 2007 according to recommendations from the expert meeting held in Salamanca in 2001." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "SBSN, selective biopsy of the sentinel lymph node." "tablatextoimagen" => array:1 [ 0 => 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"><td 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" style="border-bottom: 2px solid black">Inclusion criteria \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Exclusion criteria \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Without evidence to recommend SBSN \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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. Extensive intraductal tumors>4cm \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. Inflammatory carcinoma \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. In pregnant women \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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. In cases of multifocal tumors it is possible to perform SBSN and in multicentric tumors it is acceptable though with limited evidence de \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. Preoperative checking of node affectation through image modalities (ultrasound) and at least citology compatible with carcinoma metatastis of suspicious adenopathies \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. In cases of former augmentation or reduction mammoplasties \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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. In breast carcinomas in males it is applicable following the same guidelines followed in women \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. Existence of surgery and/or former axillary radiotherapy \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. In patients with conservative surgery and former SBSN due to carcinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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. Performing one previous excisional biopsy does not counter-indicate in the absence of exclusion criteria and if done within one (1) month \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. It is not indicated before primary systemic therapy in locally advanced carcinomas with therapeutic intent or after primary systemic therapy but in cases of specific clinical trials for the study and validation of this modality \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">5. With a good level of evidence SBSN is acceptable before primary systemic therapy with bailout purposes for conservative surgery \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">5. Axillary affectation (N1) \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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. Presence of distance metastasis \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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. Pregnant or breastfeeding women–in these patients the use of radioactive material is not indicated \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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. Former axillary surgery or radiotherapy \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab599934.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Starting 2007 the following recommendations were added following the expert meeting held in Murcia in 2006." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => 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"><td 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" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Number of patients \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Ratio of patients \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Palpation</td></tr><tr title="table-row"><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">Palpable \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Non palpable \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Radiological presentation</td></tr><tr title="table-row"><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">Node \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">141 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Microcalcifications \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Distortion \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Mixed \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Breast density</td></tr><tr title="table-row"><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">Fat \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Intermediate \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">101 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Glandular \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Location (quadrants)</td></tr><tr title="table-row"><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">Supero-external \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">103 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Supero-internal \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Infero-external \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Infero-internal \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Retroareolar \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Radioisotopic rout of injection</td></tr><tr title="table-row"><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">Deep route \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">162 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Deep+superficial route \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of the sentinel lymph node through gammagraphy</td></tr><tr title="table-row"><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">Yes \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">205 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">No \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical detection of the sentinel lymph node</td></tr><tr title="table-row"><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">Yes \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">201 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">95.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">No \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Size</td></tr><tr title="table-row"><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">≤2cm \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">136 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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 to ≤3cm \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">>3cm \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lineage</td></tr><tr title="table-row"><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">Ductal \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">180 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Lobulillar \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Mixed \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infiltration</td></tr><tr title="table-row"><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">Yes \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">139 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">No \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Mixed \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Histological differentiation</td></tr><tr title="table-row"><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">Grade I \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Grade II \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Grade III \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><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">Axillary recurrence \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab599932.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Descriptive analysis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:32 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel node mapping for breast cancer: current situation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. 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La linfogammagrafía prequirúrgica y el grado histológico del tumor se asocian a la detección quirúrgica del ganglio centinela

M. Arias Ortegaa,

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mariaariasortega@hotmail.com

Corresponding author.

, M.Y. Torres Sousab, B. González Garcíac, R. Pardo Garcíad, A. González Lópeze, M. Delgado Portelaf

a Servicio de Radiodiagnóstico, Hospital La Mancha-Centro, Alcázar de San Juan, Ciudad Real, Spain

b Servicio de Radiodiagnóstico, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain

c Servicio de Medicina Nuclear, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain

d Servicio de Cirugía General, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain

e Servicio de Obstetricia y Ginecología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain

f Servicio de Anatomía Patológica, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain

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            "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">4D Flow and 2D PCA&#46; &#40;A&#41; Quantification of the average velocity of flow in the ascending aorta through the 2D cine PCA modality&#46; To the left we can see flow direction for every vessel and to the right the chart of velocity values in the cardiac cycle&#46; &#40;B&#41; The same quantification was performed with 4D Flow&#46; Note the similarity of values of the average velocity of blood measured through 2D cine PCA and 4D Flow modalities &#40;B&#41;&#46; &#40;C&#41; Selection of the ascending aorta and the pulmonary artery in one single 4D Flow study&#46; The charts of average velocity of aorta &#40;up&#41; and pulmonary artery blood &#40;down&#41; are shown here as well&#46; In charts A and B <span class="elsevierStyleItalic">y</span>-axis is blood velocity &#40;cm&#47;s&#41; while <span class="elsevierStyleItalic">x</span>-axis is time &#40;s&#41;&#46; However&#44; in chart C <span class="elsevierStyleItalic">x</span>-axis represents the cardiac cycle divided into sixteen &#40;16&#41; different phases&#46;</p>"
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    "titulo" => "Preoperative lymphoscintigraphy and tumor histologic grade are associated with surgical detection of the sentinel lymph node"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; <span class="elsevierStyleSup">99m</span>Tc-albumin nanocolloid radioisotope transportation through lead syringe&#46; &#40;B&#41; Node with change in echogeneicity after intratumor injection of the radioisotope&#46; &#40;C&#41; Radioisotope marking of microcalcifications through an internal stereotactic metallic marker&#46; &#40;D&#41; Lymphogammagraphy &#40;anterior projection&#41; with masking and axillary sentinel node&#46; &#40;E&#41; Location of breast lesion and sentinel lymph node and design of surgical approach&#46; &#40;F&#41; Gamma-detecting portable probe model Europrobe<span class="elsevierStyleSup">&#174;</span> II&#46; &#40;G&#41; Axillary incision and tracking through gamma-detecting probe at the OR&#46; &#40;H&#41; Gamma-probe-guided ex vivo checking through of the activity of the extracted nodes&#46;</p>"
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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">Morbidity of axial lymphadenectomy is high and per se it does not increase long term survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> The trend toward more conservative treatments associated with an earlier diagnosis of breast cancer has decreased the incidence of affected axillay nodes and driven the search for valid alternatives to the total axillary lymphadenectomy&#46; The selective biopsy of the sentinel lymph node &#40;SBSN&#41; seems to be the best option&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The sentinel lymph node is the node undergoing lymphatic drainage of a tumor lesion first and directly&#46; If unaffected the remaining nodes will not be affected either&#46; On the contrary if it has tumor cells the risk that the remaining lymphatic nodes also contain tumor cells is high and a total regional lymphatic dissection is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The process of SBSN requires several units&#8211;Gynecology&#47;Surgery&#44; Radiodiagnosis&#44; Pathological Anatomy and Nuclear Medicine working together&#46; This fact introduces a wide array of clinical&#44; radiological&#44; anatomopathological or nuclear medicine variables in a process whose final goal aims at the surgical detection of the sentinel lymph node&#46; Thus the main goal of this study is to identify which one of these variables may influence the intraoperative detection of the sentinel lymph node&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0020" class="elsevierStylePara elsevierViewall">Our sample included 210 women with histological diagnosis of breast cancer between 2005 and 2010 without clinical evidence at the image modalities of metastatic axillary adenopathies who underwent SBSN&#46; The patients were diagnosed until 2007 and they met the inclusion and exclusion criteria established in the consensus meeting held in Salamanca in 2001<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#59; women diagnosed between 2007 and 2010 met the modified criteria in the meeting held in Murcia&#44; in 2006<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; This was a cross-sectional study in which all patients were recruited prospectively with the consent of the local ethical committee&#46; All of them got information on their condition and the diagnostic and therapeutical proceedings they would undergo &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; and all signed the corresponding informed written consents&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Process for the selective biopsy of the sentinel lymph node</span><p id="par0025" class="elsevierStylePara elsevierViewall">Proceeding was done in our institution under the supervision of a nuclear physician trained in a validated and consolidated working team&#46; In all cases a standard digital mammography of both breasts was performed with a mammography device Mammomat<span class="elsevierStyleSup">&#174;</span> Novation<span class="elsevierStyleSup">DR</span> &#40;Siemens AG&#44; Medical Solutions&#44; Erlangen&#44; Germany&#41;&#46; The study consisted of two &#40;2&#41; projections &#40;cranial-caudal and mi-lateral oblique&#41;&#44; additional projections when necessary and one ultrasound study of both breasts and armpits with an ultrasound device Sonoline<span class="elsevierStyleSup">&#174;</span> Antares&#8482; &#40;Siemens AG&#44; Medical Solutions&#44; Erlangen&#44; Germany&#41;&#46; All breast lesions visible through ultrasound were thick needle biopsied &#40;TNB&#41; while those identifiable only through mammography were biopsied through a stererotactic vacuum assisted system &#40;VAS&#41; on a prone table&#46; Nodes suspicious of metastasis were histologically analyzed after an ultrasound-guided TNB&#46; All biopsies and the eco-guided injection of radioisotopes were performed by the same operator&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The tracer was injected the day before the surgical intervention &#40;two-day protocol&#41;&#46; As the radioisotope the <span class="elsevierStyleSup">99m</span>Tc-albumin nanocolloid was used carried in a syringe protected by a led capsule &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; When the administration route was deep &#40;peri or intratumoral&#41; the 1&#8211;3<span class="elsevierStyleHsp" style=""></span>mCi dose was used &#40;37&#8211;111<span class="elsevierStyleHsp" style=""></span>MBq&#41; in a dilution volume of de 1&#8211;3<span class="elsevierStyleHsp" style=""></span>ml and in an injection volume of 0&#46;2&#8211;0&#46;4<span class="elsevierStyleHsp" style=""></span>ml&#46; When the administration route was superficial &#40;intradermic periareolar&#41;&#44; the dose was 0&#46;5&#8211;1<span class="elsevierStyleHsp" style=""></span>mCi &#40;18&#46;5&#8211;37<span class="elsevierStyleHsp" style=""></span>MBq&#41; in an injection volume of 0&#46;2<span class="elsevierStyleHsp" style=""></span>ml&#46; In patients with non-palpable breast cancer the radiotracer was injected inside the tumor by the Radiodiagnosis Unit with an ultrasound or stereotactic guide &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; When the tumor was palpable the injection was peritumoral and administered at the Unit of Nuclear Medicine&#46; When the sentinel lymph node was not found at the lympho-gammagraphy the tracer was injected back again in a periareolar intradermic location&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All patients underwent presurgical gammagraphy in the Unit of Nuclear Medicine the same day of the radioisotope injection&#46; Even though the gammagraphy can be done the same day of the radioisotope injection or 24<span class="elsevierStyleHsp" style=""></span>h later we decided to perform the gammagraphy on the same day to avoid underestimation of the number of sentinel lymph nodes or asynchronous uptake of different sentinel lymph nodes&#46; Images were early acquired at 30<span class="elsevierStyleHsp" style=""></span>min&#44; and lately at 2 and 4<span class="elsevierStyleHsp" style=""></span>h&#46; When breast lesions were found near the armpit the images were processed through some sort of &#8220;masking&#8221; by placing a device made out of led in the injection zone so that the nonmigrated signal would not interfere with the identification of the sentinel lymph nodes &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; After identifying the sentinel lymph nodes in the lympho-gammagraphy we proceeded to cutaneous positioning&#46; The unidentification of the sentinel lymph nodes at the gammagraphy was not an exclusion cause for the patient&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the OR the type of incision and the approach were chosen both based on the tumor and breast size and its location &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; With the help of one gamma-detecting probe the sentinel lymph node and the non-palpable tumors could be found &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Sentinel lymph node was said to have a greater number of counts&#46; If activity shown was &#8805;10&#37; of maximum activity secondary sentinel lymph nodes were looked for and found &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The SBSN intervention with axillary digital exploration was concluded&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The pathological examination of both the sentinel lymph node and the nodes obtained in the axillary lymphadenectomy was deferred in 176 patients and performed intraoperatively in the last 34 patients because since 2010 the Anatomical Pathological Section uses one R-100i analyzer allowing us to perform the One Step Acid Nucleic Amplification &#40;OSNA<span class="elsevierStyleSup">&#174;</span>&#41; molecular biological analysis intraoperatively&#46; The nodes that were studied in a deferred way were processed with hematoxiline&#8211;eosine and if results were negative for malignancy one immunohistochemical study was performed too&#46; When this immunohistochemical study was positive the diagnosis was metastasis&#59; if negative the conclusion was that the sentinel lymph node was negative&#46; In the histopathological study macrometastases were tumor deposits &#62;2<span class="elsevierStyleHsp" style=""></span>mm&#44; micrometastases were tumor deposits between 0&#46;2 and 2<span class="elsevierStyleHsp" style=""></span>mm while foci &#60;0&#46;2<span class="elsevierStyleHsp" style=""></span>mm were said to be isolated tumor cells&#46; For the nodes studied intraoperatively through the R-100i analyzer&#44; &#8220;&#43;&#43;&#8221; was considered macrometastasis&#44; &#8220;&#43;&#8221; micrometastasis&#44; and &#8220;&#8722;&#8221; absence of metastasis&#44; isolated cells or pollution&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data mining and statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">For the descriptive analysis data were gathered on age&#44; palpation&#44; radiological presentation&#44; breast density&#44; location of lesion in the breast&#8211;lesions located in the junction of quadrants were considered to be located clockwise in the second quadrant&#44; the injection route of radioisotope&#44; the detection of the sentinel lymph node in the lympo-gammagraphy&#44; the detection of the sentinel lymph node at the OR&#44; the tumor size&#44; the degree of histological differentiation and the number of axillary relapses &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Data were gathered prospectively by an independent investigator in a table of variables and analyzed with the statistical program SPSS<span class="elsevierStyleSup">&#174;</span> v&#46;15&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">In an effort to study the variables associated with the surgical detection of the sentinel lymph node a logistic regression analysis was performed with overall data on the sample &#40;210 patients&#41;&#46; After a review of the available medical literatura<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;16</span></a> we chose both the most relevant variables and those that might be associated&#46; In our multivariate logistic regression model were tagged as a dependent variable the surgical detection of the sentinel lymph node and as independent variables the radiological presentation&#44; the radiological density&#44; the location of the lesion&#44; the route of the injection of the radioisotope&#44; the detection of the sentinel lymph node in the lympo-gammagraphy&#44; the size of lesion&#44; the histological lineage and the degree of histological differentiation of lesion&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Simple logistic regressions were performed for every independent variable&#46; The less significant variables were eliminated from the major model one by one until obtaining an abridged model including variables with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;15 only&#46; The interactions among variables included in our abridged model were assessed together with the test of ratio of verisimilitude&#46; One multivariate model with variables showing influence was performed and the predictive ability of the model by studying through the area under the receiver operating characteristic &#40;ROC&#41; curve&#44; the odds ratio &#40;OR&#41; and the confidence interval at 95&#37; &#40;95&#37; CI&#41; were estimated for these variables&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Descriptive analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The average age of patients was 54 years old with-ranging between 25 and 87 years old&#46; In 48&#46;1&#37; of patients breast density was intermediate&#46; The most widely used injection route of the radioisotope was the isolated deep one &#40;72&#46;7&#37;&#41;&#46; Most lesions were palpable &#40;57&#46;1&#37;&#41;&#44; presenting as nodes &#40;67&#46;1&#37;&#41;&#44; &#60;2<span class="elsevierStyleHsp" style=""></span>cm &#40;64&#46;8&#37;&#41;&#44; localized in the supero-external quadrant &#40;49&#46;1&#37;&#41; and usually ductal carcinomas &#40;85&#46;7&#37;&#41; with infiltration &#40;66&#46;2&#41; and grade II in histological differentiation &#40;44&#46;8&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The sentinel lymph node was found in 97&#46;6&#37; of preoperative gammagraphies while at the OR it was found in 95&#46;7&#37; of patients&#46; During the follow-up of patients axillary relapse could be found &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Multivariate logistics regression analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">Data from the final model showed that when the sentinel lymph node was detected in the lympho-gammagraphy the OR was 50&#46;28 &#40;95&#37; CI&#58; 6&#46;107&#8211;414&#46;966&#41;&#46; When it comes to lesions with histological differentiation grade II the OR was 0&#46;577 &#40;95&#37; IC&#58; 0&#46;077&#8211;4&#46;343&#41;&#44; for grade III the OR was 0&#46;224 &#40;95&#37; IC&#58; 0&#46;03&#8211;1&#46;655&#41;&#46; The test of ratio of verisimilitude showed that the variables eliminated did not add any additional information to the model&#46; There were no atypical values capable of altering our results&#46; The area under the curve showed a prediction percentage of our model of 0&#46;75 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">In our study we tried to show that the surgical detection of the sentinel lymph node is significantly associated with the prior gammagraphic detection of the sentinel lymph node and the degree of histological differentiation of the tumor&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The limitation in the access to this modality can be due to the fact that some studies analyzed the utility of lympho-gammagraphy inside the process of SBSN&#46; However according to our results patients whose sentinel lymph node&#47;s has&#47;have are detected through the lympho-gammagraphy &#40;in equal conditions to other variables&#41; have a 50&#46;280 times greater probability for the node&#47;s to also be surgically detected than patients whose tests were negative&#46; Gammagraphy is useful in patients with a history of interventions in order to show the absence of the sentinel lymph node but also to detect sentinel lymph nodes of atypical localization&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Some studies recommend gammagraphies since they can assess the axillary status and predict the number of sentinel lymph nodes to be extracted&#8211;even the node&#47;s histological status&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Also to prevent further complications due to lack of diffusion of the radiotracer or spreading to atypical locations&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However for some authors it does not improve the surgical detection of the sentinel lymph node&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> It has been said that gammagraphy is also effective to assess the status of sentinel lymph nodes and that their negative or positive result can be associated with the number of sentinel lymph nodes surgically removed&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The same way there are studies that indicate that the SBSN modality can be developed in hospitals without nuclear medicine since such modality does not imply greater survival recurrence or reduction in patients&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> As a matter of fact the unidentification of the sentinel lymph node in the lympho-gammagraphy should not be an exclusion criterion for the SBSN modality&#46; In any case our results recommend to keep on performing sentinel lymph node detection gammagraphies before the surgical gammagraphies&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">For Krausz et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> the tumor grade was the only significant variable&#58; the higher the grade the more aggressive the tumor is and the higher the likelihood of node metastasis&#46; This is consistent with our results that indicate one direct association between the tumor grade and the likelihood of failure in the detection of the sentinel lymph node at the OR&#46; In this sense some studies indicate that the in situ ductal carcinoma&#44; the low likelihood of axillar metastasis should lead us to resect the tumor without performing SBSN which would only be used for cases in which in situ ductal carcinoma is a palpable mass showing extensive microcalcifications or when being multicentric&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Our study shows that one grade II patient&#8211;all other variables being equal is 0&#46;6 times more likely to have the sentinel lymph node detected surgically than when we are talking about a grade I patient&#46; On the other hand in a grade III lesion&#8211;all other variables being equal the likelihood is 0&#46;2 lower than in a grade I lesion&#46; High grade-tumors have a greater tendency to metastazise in axillary nodes&#44; increase the number of false negatives&#44; reduce the negative predictive value of SBSN and increase the number of axillary recurrences&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The most common cause to prevent tracer migration is metastatic axillary blockade&#46; This can explain why the histologic tumor grade is associated with the surgical detection of the sentinel lymph node since the proportion of positive axillary nodes is greater in patients who do not show any tracer migrations&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Even though this can lead us to perform one axillary lymphadenectomy when the sentinel lymph node is not detected in the lymphogammagraphy our attitude should not be excluding the SBSN even after late sequences and the reinjection of radioisotopes due to the probability of surgical detection through the gamma-detecting probe&#46; This is especially important in nodes whose location in the armpit makes it hard to detect them through the gammacamera&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">There is a great methodological disparity in the SBSN yet the results we got are similar to the ones published and generally accepted as optimal results by most authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;27</span></a> The ROC area under the curve obtained shows an optimal discrimination of our model to be able to predict in what patients the sentinel lymph node will be detected in the OR and in what patients&#59; by the way we have not found any similar studies on this regard&#46; In the associative model we included another six &#40;6&#41; variables controversial on former studies without the surgical detection of the sentinel lymph node being significant&#46; We have not found any recent studies on the relation between the radiological presentation of the tumor and the surgical detection of the sentinel lymph node&#46; In our study the relation with any forms of presentation has not been significant probably because the surgical detection of the sentinel lymph node is based on the degree of infiltration and the histological grade rather than the form of presentation of image studies&#46; In other studies it was observed that there was a statistically significant relation between the body mass index &#40;BMI&#41; and the non-detection of the sentinel lymph node in the lympho-gammagraphy maybe because in the fatty breasts there is an insufficient lymphatic network to be able to transfer the tracer&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Our study did not replicate this association probably because there is not always a correlation between a greater BMI and a greater quantity of breast fat&#46; Similarly for some authors the probability of surgically detecting the sentinel lymph node is greater in tumors located at the superior-external quadrant of the breast than in those found at the infero-internal quadrant&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Nevertheless the location of the tumor at the supero-external quadrant can make the non-migrated radioisotope signal interfere with that of the sentinel lymph node&#46; In our study no quadrants showed a significant relation with the surgical detection of the sentinel lymph node maybe because the tracer migration was forced through superficial route in cases where it could not be detected in the lympho-gammagraphy&#8211;with masking if necessary&#44; because the sentinel lymph nodes were signaled and their identification facilitated at the OR&#46; When it comes to the possible combinations of the injection of the <span class="elsevierStyleSup">99m</span>Tc radioisotope&#8211;through superficial or deep route and with the association &#40;or not&#41; of colorants several studies have analyzed its relation with technical efficacy<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;12&#8211;14&#44;29&#8211;31</span></a> while showing that the sentinel lymph node is usually associated with the superficial route&#46; In our study nor the isolated deep injection or the deep injection with superficial injection of the marker <span class="elsevierStyleSup">99m</span>Tc have been closely associated with the surgical detection of the sentinel lymph node probably because we always force migration through one superficial injection if the deep injection has not given any results in the previous lymphography&#46; Tumor size increases the number of sentinel lymph nodes extracted through SBSN<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> as well as the likelihood that other non-sentinel lymph nodes are affected&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> As a matter of fact in non-palpable lesions the efficacy of the technique is lower than in palpable ones&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Some authors claim that the bigger the tumor size the lower the detection rate&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> For other authors however tumor size is not a determining factor<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> which is consistent with our results&#46; We have not found former published studies analyzing the relation between the histological lineage of tumor lesion and the surgical detection of the sentinel lymph node and our results have not shown a significant relation either&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Our study is limited by the sample size number which does not allow us to have the recommended number of patients in each subcategory and is also limited by the great variability of methods used in each institution which in turn does not allow us to perform a reliable comparison of results&#46; Our findings should be confirmed in future studies with larger samples yet for the time being we believe it is very convenient to keep on performing preoperative lympho-gammagraphies&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In sum both the preoperative lympho-gammagraphy and the histologic tumor grade influence on the surgical detection of the sentinel lymph node in such a way that patents with high histologic tumor grades or those whose sentinel lymph node&#47;s has&#47;have not be detected in the preoperative lympho-gammagraphy there is a greater probability of not detecting it during the intervention either&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical responsibilities</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protection of people and animals</span><p id="par0105" class="elsevierStylePara elsevierViewall">Authors confirm that no experiments have been performed on human beings or animals&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Data confidentiality</span><p id="par0110" class="elsevierStylePara elsevierViewall">Authors confirm that the protocols of their centers have been followed on matters concerning the publishing of data from patients&#46; They also confirm that all patients included in this study have been given enough information and handed over their written informed consent for their participation in this study&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">Authors confirm that in this report there are no personal data of patients&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Authors</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0125" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study&#58; MAO and MYTS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0130" class="elsevierStylePara elsevierViewall">Original idea of the study&#58; MAO and MYTS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0135" class="elsevierStylePara elsevierViewall">Study design&#58; MAO and MYTS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0140" class="elsevierStylePara elsevierViewall">Data mining&#58; MAO&#44; MYTS&#44; BGG&#44; RPG&#44; AGL and MDP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0145" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; MAO&#44; MYTS&#44; BGG&#44; RPG&#44; AGL and MDP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6</span><p id="par0150" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; MAO and MYTS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7</span><p id="par0155" class="elsevierStylePara elsevierViewall">Reference search&#58; MAO&#44; MYTS and BGG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8</span><p id="par0160" class="elsevierStylePara elsevierViewall">Writing&#58; MAO&#44; MYTS&#44; BGG&#44; RPG&#44; AGL and MDP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9</span><p id="par0165" class="elsevierStylePara elsevierViewall">Manuscript critical review with intellectually relevant contributions&#58; SCC MAO&#44; MYTS&#44; BGG&#44; RPG&#44; AGL and MDP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10</span><p id="par0170" class="elsevierStylePara elsevierViewall">Final version approval&#58; MAO&#44; MYTS&#44; BGG&#44; RPG&#44; AGL and MDP&#46;</p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflict of interests</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors reported no conflicts of interests&#46;</p></span></span>"
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              "titulo" => "Process for the selective biopsy of the sentinel lymph node"
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    "fechaRecibido" => "2012-08-05"
    "fechaAceptado" => "2012-11-22"
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            0 => "Sentinel node biopsy"
            1 => "Breast cancer"
            2 => "Surgery"
            3 => "Nuclear imaging"
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          "palabras" => array:4 [
            0 => "Biopsia del ganglio centinela"
            1 => "C&#225;ncer de mama"
            2 => "Cirug&#237;a"
            3 => "Imagen nuclear"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To study which variables involved in the process of selective sentinel node biopsy &#40;SSNB&#41; influence the intraoperative detection of the sentinel lymph node&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was a prospective cross-sectional study in 210 patients &#40;mean age&#44; 54 years&#41; diagnosed with breast cancer who underwent SSNB&#46; We recorded clinical&#44; radiological&#44; radioisotope administration&#44; surgical&#44; and histological data as well as follow-up data&#46; We did a descriptive analysis of the data and an associative analysis using multivariable regression&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Deep injection alone was the most common route of radioisotope administration &#40;72&#46;7&#37;&#41;&#46; Most lesions were palpable &#40;57&#46;1&#37;&#41;&#44; presented as nodules &#40;67&#46;1&#37;&#41;&#44; measured less than 2<span class="elsevierStyleHsp" style=""></span>cm in diameter &#40;64&#46;8&#37;&#41;&#44; were located in the upper outer quadrant &#40;49&#46;1&#37;&#41;&#44; were ductal carcinomas &#40;85&#46;7&#37;&#41;&#44; were accompanied by infiltration &#40;66&#46;2&#37;&#41;&#44; and had a histologic grade of differentiation of II &#40;44&#46;8&#37;&#41;&#46; Preoperative scintigraphy detected the sentinel node in 97&#46;6&#37; of cases and 95&#46;7&#37; were detected during the operation&#46; One axillary relapse was observed&#46; In the associative study&#44; the variables &#8220;preoperative lymphoscintigraphy&#8221; and &#8220;histologic grade of differentiation of the tumor&#8221; were significantly associated with the detection of the sentinel lymph node during the operation&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The probability of not detecting the sentinel lymph node during the surgical intervention is higher in patients with high histologic grade tumors or in patients in whom preoperative lymphoscintigraphy failed to detect the sentinel node&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Estudiar qu&#233; variables implicadas en el proceso de la biopsia selectiva del ganglio centinela &#40;BSGC&#41; influyen en la detecci&#243;n intraoperatoria del ganglio centinela&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal prospectivo de 210 pacientes &#40;edad media&#58; 54 a&#241;os&#41; diagnosticadas de c&#225;ncer de mama a las que se les realiz&#243; BSGC&#46; Se recogieron los datos cl&#237;nicos y radiol&#243;gicos&#44; de la administraci&#243;n del radiois&#243;topo&#44; quir&#250;rgicos&#44; de anatom&#237;a patol&#243;gica y de seguimiento&#44; y se realiz&#243; un an&#225;lisis descriptivo y asociativo mediante una regresi&#243;n m&#250;ltiple multivariante&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La v&#237;a de inyecci&#243;n del radiois&#243;topo m&#225;s utilizada fue la profunda aislada &#40;72&#44;7&#37;&#41;&#46; La mayor&#237;a de las lesiones fueron palpables &#40;57&#44;1&#37;&#41;&#44; se presentaron como n&#243;dulos &#40;67&#44;1&#37;&#41;&#44; fueron menores de 2<span class="elsevierStyleHsp" style=""></span>cm &#40;64&#44;8&#37;&#41;&#44; se localizaron en el cuadrante supero-externo &#40;49&#44;1&#37;&#41;&#44; se trataba de carcinomas ductales &#40;85&#44;7&#37;&#41;&#44; con infiltraci&#243;n &#40;66&#44;2&#37;&#41; y el grado de diferenciaci&#243;n histol&#243;gica fue II &#40;44&#44;8&#37;&#41;&#46; Con la gammagraf&#237;a prequir&#250;rgica se detect&#243; el ganglio centinela en el 97&#44;6&#37; de los casos&#44; y en el quir&#243;fano el 95&#44;7&#37;&#46; Se observ&#243; una recurrencia axilar&#46; En el estudio asociativo&#44; las variables &#171;linfogammagraf&#237;a prequir&#250;rgica&#187; y &#171;grado de diferenciaci&#243;n histol&#243;gica del tumor&#187; mostraron una asociaci&#243;n estad&#237;sticamente significativa con la detecci&#243;n del ganglio centinela en el quir&#243;fano&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La probabilidad de no detectar el ganglio centinela durante la intervenci&#243;n quir&#250;rgica es mayor en los pacientes con tumores de alto grado histol&#243;gico o en las que no se ha conseguido verlo en la linfogammagraf&#237;a prequir&#250;rgica&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Arias Ortega M&#44; Torres Sousa MY&#44; Gonz&#225;lez Garc&#237;a B&#44; Pardo Garc&#237;a R&#44; Gonz&#225;lez L&#243;pez A&#44; Delgado Portela M&#46; La linfogammagraf&#237;a prequir&#250;rgica y el grado histol&#243;gico del tumor se asocian a la detecci&#243;n quir&#250;rgica del ganglio centinela&#46; Radiolog&#237;a&#46; 2014&#59;56&#58;515&#8211;523&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; <span class="elsevierStyleSup">99m</span>Tc-albumin nanocolloid radioisotope transportation through lead syringe&#46; &#40;B&#41; Node with change in echogeneicity after intratumor injection of the radioisotope&#46; &#40;C&#41; Radioisotope marking of microcalcifications through an internal stereotactic metallic marker&#46; &#40;D&#41; Lymphogammagraphy &#40;anterior projection&#41; with masking and axillary sentinel node&#46; &#40;E&#41; Location of breast lesion and sentinel lymph node and design of surgical approach&#46; &#40;F&#41; Gamma-detecting portable probe model Europrobe<span class="elsevierStyleSup">&#174;</span> II&#46; &#40;G&#41; Axillary incision and tracking through gamma-detecting probe at the OR&#46; &#40;H&#41; Gamma-probe-guided ex vivo checking through of the activity of the extracted nodes&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Exclusion criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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; No evidence of clinical axillary or ultrasound &#40;N0&#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; Non-acceptance from the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; Invasive tumors with a major diameter<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>cm &#40;T1&#44; T2&#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&#46; Breast cancer T3 and T4 and inflammatory &#40;stages of high probability of axillary affectation being the search for the sentinel lymph node not a priority&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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&#46; Intraductal tumors&#58; &#40;a&#41; if mastectomy is indicated&#59; &#40;b&#41; high nuclear grade and&#47;or comedocian&#59; &#40;c&#41; suspicion of microinvasion&#59; and &#40;d&#41; extensive &#40;&#62;5<span class="elsevierStyleHsp" style=""></span>cm&#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&#46; Multicentric lesions &#40;due to the existence of several foci independent from the primary tumor each one of which can have a different lymphatic drainage route which in turn can increase the rate of false negatives&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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&#46; Multifocal breast cancer when the biggest lesion size was &#60;3<span class="elsevierStyleHsp" style=""></span>cm&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&#46; Axillary affectation &#40;N1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">5&#46; Presence of distance metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">6&#46; Pregnant or breastfeeding women &#40;in these patients the use of radioactive material is not indicated&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">7&#46; Surgery or prior axially radiotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Inclusion and exclusion criteria of patients until 2007 according to recommendations from the expert meeting held in Salamanca in 2001&#46;</p>"
        ]
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      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">SBSN&#44; selective biopsy of the sentinel lymph node&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => 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"><td 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" style="border-bottom: 2px solid black">Inclusion criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Exclusion criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Without evidence to recommend SBSN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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; Extensive intraductal tumors<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm&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; Inflammatory carcinoma&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; In pregnant women&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; In cases of multifocal tumors it is possible to perform SBSN and in multicentric tumors it is acceptable though with limited evidence de&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; Preoperative checking of node affectation through image modalities &#40;ultrasound&#41; and at least citology compatible with carcinoma metatastis of suspicious adenopathies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; In cases of former augmentation or reduction mammoplasties&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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&#46; In breast carcinomas in males it is applicable following the same guidelines followed in women&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&#46; Existence of surgery and&#47;or former axillary radiotherapy&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&#46; In patients with conservative surgery and former SBSN due to carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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&#46; Performing one previous excisional biopsy does not counter-indicate in the absence of exclusion criteria and if done within one &#40;1&#41; month&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&#46; It is not indicated before primary systemic therapy in locally advanced carcinomas with therapeutic intent or after primary systemic therapy but in cases of specific clinical trials for the study and validation of this modality&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="" 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" 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">5&#46; With a good level of evidence SBSN is acceptable before primary systemic therapy with bailout purposes for conservative surgery&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">5&#46; Axillary affectation &#40;N1&#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="" 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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">6&#46; Presence of distance metastasis&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="" 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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">7&#46; Pregnant or breastfeeding women&#8211;in these patients the use of radioactive material is not indicated&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="" 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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">8&#46; Former axillary surgery or radiotherapy&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="" 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></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Starting 2007 the following recommendations were added following the expert meeting held in Murcia in 2006&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
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            0 => 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"><td 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" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Number of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Ratio of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Palpation</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Palpable&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Non palpable&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Radiological presentation</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Node&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">141&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Microcalcifications&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Distortion&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Mixed&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&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
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Breast density</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Fat&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&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="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Intermediate&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">101&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Glandular&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Location &#40;quadrants&#41;</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Supero-external&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Supero-internal&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Infero-external&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Infero-internal&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Retroareolar&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Radioisotopic rout of injection</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Deep route&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">162&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Deep<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>superficial route&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Detection of the sentinel lymph node through gammagraphy</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Yes&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">205&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>No&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&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\ttop\n
                  \t\t\t\t">2&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Surgical detection of the sentinel lymph node</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Yes&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">201&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>No&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Size</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>&#8804;2<span class="elsevierStyleHsp" style=""></span>cm&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>&#62;2 to &#8804;3<span class="elsevierStyleHsp" style=""></span>cm&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>&#62;3<span class="elsevierStyleHsp" style=""></span>cm&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Lineage</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Ductal&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
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2012.11.004

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Year/Month	Html	Pdf	Total

2024 April	1	0	1
2024 January	2	0	2
2023 December	1	0	1
2023 August	1	0	1
2023 March	1	0	1
2023 January	1	0	1
2018 May	0	1	1
2018 April	16	2	18
2018 March	13	1	14
2018 February	5	3	8
2018 January	10	1	11
2017 December	11	1	12
2017 November	7	4	11
2017 October	13	1	14
2017 September	19	1	20
2017 August	30	6	36
2017 July	16	1	17
2017 June	22	3	25
2017 May	26	2	28
2017 April	33	11	44
2017 March	17	30	47
2017 February	9	7	16
2017 January	8	2	10
2016 December	8	1	9
2016 November	8	1	9
2016 October	26	8	34
2016 September	12	2	14
2016 August	11	3	14
2016 July	20	1	21
2016 June	36	9	45
2016 May	24	12	36
2016 April	18	6	24
2016 March	28	10	38
2016 February	29	14	43
2016 January	32	16	48
2015 December	22	10	32
2015 November	17	8	25
2015 October	27	7	34
2015 September	15	6	21
2015 August	16	4	20
2015 July	14	5	19
2015 June	16	3	19
2015 May	13	5	18
2015 April	0	1	1
2015 February	1	0	1
2015 January	0	1	1

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