Prognosis and treatment of acrometastases: Observational study of 35 cases treated in a single institution | Revista Española de Cirugía Ortopédica y Traumatología (English Edition)

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Bartra, J.-R. Caeiro, M. Mesa-Ramos, I. Etxebarría-Foronda, J. Montejo, P. Carpintero, F. Sorio-Vilela, S. Gatell, L. Canals" "autores" => array:10 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Bartra" ] 1 => array:2 [ "nombre" => "J.-R." "apellidos" => "Caeiro" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Mesa-Ramos" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Etxebarría-Foronda" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Montejo" ] 5 => array:2 [ "nombre" => "P." "apellidos" => "Carpintero" ] 6 => array:2 [ "nombre" => "F." "apellidos" => "Sorio-Vilela" ] 7 => array:2 [ "nombre" => "S." "apellidos" => "Gatell" ] 8 => array:2 [ "nombre" => "L." 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Machado, M. San-Julian" "autores" => array:2 [ 0 => array:4 [ "nombre" => "V." "apellidos" => "Machado" "email" => array:1 [ 0 => "vmachado@unav.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "San-Julian" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Cirugía Ortopédica y Traumatología, Clínica Universidad de Navarra, Pamplona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pronóstico y tratamiento de las acrometástasis: estudio observacional de 35 casos tratados en un único centro" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 421 "Ancho" => 1405 "Tamanyo" => 61601 ] ] "descripcion" => array:1 [ "en" => "Plain anteroposterior and lateral X-ray (a and b) and MRI (c) of a bone metastasis in the tibia, in a women of 45 years with breast cancer with multiple bone metastasis, treated with curettage, cryosurgery, cement fill and plate stabilisation (d); (e) 10 years after surgery the patient is able to undertake all her daily activities without outside help." ] ] ] "textoCompleto" => "IntroductionBone metastases are the most common oncological process affecting the bones. The axial skeleton is more frequently affected than the appendicular skeleton. In all long bone involvement, metastases distal to the elbow and knee, or acrometastases, are the least frequent; comprising barely .1% and 7% of all bone metastases.<a class="elsevierStyleCrossRefs" href="#bib0110">1–5</a> In general, the more distal the bone, the less red bone marrow it contains, and therefore its involvement is more rare.<a class="elsevierStyleCrossRef" href="#bib0135">6</a>The term “acrometastasis” is used indiscriminately in the literature to refer to “bone metastases in the distal regions of the extremities”,<a class="elsevierStyleCrossRef" href="#bib0140">7</a> or in some cases is only used for metastases affecting the wrist or the bones of the hands and feet.<a class="elsevierStyleCrossRefs" href="#bib0145">8–11</a> However, most articles define acrometastasis expressly as bone metastasis distal to the elbow and knee,<a class="elsevierStyleCrossRefs" href="#bib0115">2,4,5,12–14</a> as in our case.A primary tumour of the lung has been described in the literature as most commonly causing acrometastasis.<a class="elsevierStyleCrossRefs" href="#bib0110">1,2,4,9,12–15</a> However, a primary in the kidney is the most common in some series on lower limb acrometastasis.<a class="elsevierStyleCrossRefs" href="#bib0135">6,7</a> The tibia is the bone most frequently affected by acrometastasis.<a class="elsevierStyleCrossRefs" href="#bib0110">1,5</a>Involvement of the distal bones is considered a factor of poor prognosis, since it implies wide disease spread. The described mean survival is from 3 to 9 months from diagnosis of distal metastasis,<a class="elsevierStyleCrossRefs" href="#bib0120">3,6,7,9,13,14</a> with poor results for patients with no known primary tumour.<a class="elsevierStyleCrossRef" href="#bib0140">7</a>The objective of this study was to determine the most frequent location of acrometastases, the primary tumour most commonly associated with metastases distal to the elbow and the knee, and to assess the different surgical options for acrometastasis according to estimated patient survival.Material and methodsWe performed a retrospective study of patients with bone metastasis distal to the elbow and the knee, diagnosed or treated in our centre's department of orthopaedic and trauma surgery from 1988 to 2016, with a mean follow-up of 28 months (3–121 months). The treatment of each patient was individualised after the relevant multidisciplinary assessment.Epidemiological variables and information were gathered about the primary tumour and the location of distal metastases, number of metastases, symptoms prior to diagnosis, time between diagnosis of primary tumour and diagnosis of distal metastasis, treatment of acrometastasis, and survival time from diagnosis of the distal metastasis.Statistical analysis was performed using Fisher's exact test to compare proportions and Welch's test to compare means, with STATA 12.0 software, considering p<.05 as statistically significant.ResultsOur series comprised 21 patients affected by bone metastases distal to the elbow and knee. Seven patients had unique metastases and 14 had multiple metastases, either bone or visceral. There were a total of 35 acrometastases: 4 in the upper limbs (2 in the radius, one in the ulna and one in the first metacarpal), and 31 in the lower limbs (13 in the tibia, 5 in the calcaneus, 5 in the wedges, 2 in the talus, one in the fibula, one in the scaphoid, and one in the cuboid).The mean age of the patients was 48 (range 8–74 years), although the median was 55 years. The distribution by sex shows a clear male predominance: 14 men compared to 7 women.The time between diagnosis of the primary tumour and diagnosis of acrometastasis was 41 months (range 0–150). Seven patients had no known primary tumour before diagnosis of acrometastasis; 6 of them had a unique metastasis (p=.001), i.e., we found a statistically significant relationship between the onset of disease with distal bone metastasis and it being a unique metastasis.The main symptom reported by patients was pain (n=13, 62%); 3 of these patients had a pathological fracture (14%). Others consulted when they noticed a palpable mass (n=3, 14%). For the remainder (24%) diagnosis was by extension studies since, at the time of diagnosis, the patients were asymptomatic.The most common primary tumours were of the kidney (n=3 patients; 4 of the 35 acrometastases) and the lung (n=3 patients; 3 of the 35 acrometastases). Prostate carcinoma, although only observed in 2 patients, was responsible for 12 of the 35 acrometastases. The other primary tumours are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The primary that most frequently caused distal metastases in the lower limb was hypernephroma (19%), followed by adenocarcinoma of the lung (13%). In the upper limb, however, a lung primary was the most common (25%).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The treatment received by patients was individualised in each case according to the location of the metastasis and especially the prognosis of the primary tumour, the most frequent (n=10) being en bloc resection plus reconstruction with autologous or heterologous structural graft (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Other options were cryosurgery and cement fill (n=2) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), intramedullary nail fixation (n=1), amputation (n=1) and surgical abstention (n=7).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Of the 21 patients, 11 died (52.4%), 7 are alive with progressive disease, and 3 with disease in remission. Of the 11 patients who died, 10 had multiple metastases. The mean patient survival was 42 months (1–121 months), with no statistically significant differences between patients with unique metastases and those with multiple metastases (p=.9), although this might be due to the small sample size and the variety of patients included in the study.DiscussionA diagnosis of metastasis distal to the elbow and knee poses a major challenge since, because it is so rare is often not considered, particularly when there is no known primary tumour.<a class="elsevierStyleCrossRefs" href="#bib0110">1,8,10,16</a> Acrometastases can be the first manifestation of an oncological process in up to 10% of cases.<a class="elsevierStyleCrossRefs" href="#bib0165">12,14</a> In our series this percentage was higher (33%), probably because we only included cases that had been diagnosed or treated in the orthopaedic and trauma surgery department, without considering cases that had not been referred to us because surgical treatment had not been advised for them.In our series, as in other published series, such as those of Baran,<a class="elsevierStyleCrossRef" href="#bib0135">6</a> Lamarca,<a class="elsevierStyleCrossRef" href="#bib0140">7</a> Mavrogenis<a class="elsevierStyleCrossRef" href="#bib0165">12</a> and Libson,<a class="elsevierStyleCrossRef" href="#bib0190">17</a> a location distal to the knee is more frequently associated with infradiaphragmatic tumours. Specifically, in our series, hypernephroma was responsible for 19% of the acrometastases of the lower limbs. However, metastases distal to the elbow are more often associated with supradiaphragmatic tumours, such as the lung or thyroid. Some publications that do not specify whether the acrometastasis affected an upper or a lower limb, assert that the primary tumour most often associated with acrometastasis is that of the lung (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The treatment of distal metastases depends on the prognosis of the primary tumour; therefore a multidisciplinary approach is essential. Surgical treatment has a place beyond prophylactic osteosynthesis or amputation. Although the literature refers to a poor prognosis, we chose en bloc resection plus reconstruction with graft for most of our patients thanks to the multidisciplinary approach taken. It is important to assess each case individually, according to the number and location of the metastasis, the response of the primary tumour to systemic treatments, the patient's general condition and the functionality that might be achieved with surgery. In short, in the case of unique metastases from hypernephroma, en bloc resection followed by reconstruction increases survival.<a class="elsevierStyleCrossRef" href="#bib0205">20</a> Similarly, in the case of breast cancer, treatments should be planned that help not only to relieve pain, but also to reduce tumour load and preserve limb function, because these patients now have long survival.Despite the fact that amputation is one of the most recommended surgical techniques in some series on bone metastases in the hands and feet,<a class="elsevierStyleCrossRefs" href="#bib0120">3,11,21</a> it is not the only surgical option. Although reasonable in the case of metastatic involvement of the phalanges, it can cause great functional alteration if there is more proximal involvement. Therefore, and bearing in mind the survival observed in our series, we do not consider amputation the technique of choice; more conservative surgical treatment could be justified, as long as they did not compromise the patient's prognosis, although studies are required with a greater number of cases to confirm this.Bone metastases distal to the elbow and knee do not necessary mean a poor prognosis, especially when they are unique metastases. In our series, although 11 (52%) of the patients died, their mean survival was 42 months from diagnosis of the distal metastasis, and this is 6 times higher than that described in the literature. This is explained by the high number of unique metastases observed in our series, which indicates less disease spread.Given that these metastases are so rare compared to axial bone metastases, the series we present is small, and therefore the evidence provided is limited. Furthermore, our series includes 2 cases with bone metastasis in the proximal tibia, which cannot be considered strictly acrometastases. Another limitation of the study to consider is that only cases diagnosed or treated in the orthopaedic and trauma surgery department were included, without considering the cases that the oncologist did not refer to our department, and therefore there might be a bias in estimating the survival.Level of evidenceLevel of evidence IV.Conflicts of interestThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1135245" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1067345" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1135246" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1067344" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Level of evidence" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack386401" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-14" "fechaAceptado" => "2018-05-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1067345" "palabras" => array:4 [ 0 => "Acrometastases" 1 => "Distal bone metastases" 2 => "Surgical treatment" 3 => "Survival" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1067344" "palabras" => array:4 [ 0 => "Acrometástasis" 1 => "Metástasis óseas distales" 2 => "Tratamiento quirúrgico" 3 => "Supervivencia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveThere is a degree of contradiction in the literature about the primary tumour that is most frequently associated with acrometastases, as well as their prognosis and treatment. The aim of this study is to determine the most frequent location of the acrometastases, the most frequent primary tumour according to its location, and to evaluate the surgical options according to the estimated survival. MethodsA retrospective study on patients diagnosed with acrometastases. The primary tumour, as well as the number, location, symptoms and treatment of the acrometastases and survival rate were collected. Results35 acrometastases in 21 patients were reviewed: 4 in the upper limbs and 31 in the lower limbs; the tibia was the most frequently affected bone (n=13). The primary tumour that most frequently produced acrometastases in the lower limb was hypernephroma (19%). In the upper limb lung tumour was more frequent (25%). Eleven patients died (52%); 10 of them had concomitant multiple metastases. The mean survival was 42 months from the diagnosis of acrometastases. ConclusionAcrometastases are more frequently seen in the lower extremities and the most frequent tumour was hypernephroma followed by lung. The treatment of acrometastases depends on the prognosis of the primary tumour, so a multidisciplinary approach is essential. The mean survival in our series did not imply a poorer prognosis for acrometastases, so it is feasible to consider surgical options such as wide resection and reconstruction. A unique acrometastases is a good prognosis signal." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoExiste cierta contradicción en la literatura acerca del tumor primario que se asocia con más frecuencia a las acrometástasis, así como acerca de su pronóstico y tratamiento. El objetivo de nuestro trabajo es determinar la localización más frecuente de las acrometástasis, el tumor primario más frecuente según su localización y evaluar las opciones quirúrgicas en función de la supervivencia estimada. MétodosHemos realizado un estudio retrospectivo de los pacientes diagnosticados de acrometástasis en nuestra institución. Se recogieron variables epidemiológicas, así como información acerca de tumor primario y número, localización, síntomas y tratamiento de las acrometástasis. ResultadosSe revisaron 35 acrometástasis en 21 pacientes: 4 en miembros superiores y 31 en miembros inferiores, siendo la tibia el hueso más frecuentemente afectado (n=13). El tumor primario que con más frecuencia produce acrometástasis en miembros inferiores es el hipernefroma (19%); en los miembros superiores, sin embargo, el pulmón fue más frecuente (25%). Once pacientes fallecieron (52%), de los cuales 10 tenían metástasis en múltiples localizaciones. La media de supervivencia fue de 42 meses desde el diagnóstico de las acrometástasis. ConclusiónLas acrometástasis se observan con más frecuencia en las extremidades inferiores, y el tumor primario más frecuente es el hipernefroma, seguido del de pulmón. El tratamiento de las acrometástasis depende del pronóstico del paciente, por lo que es esencial un abordaje multidisciplinar. La media de supervivencia en nuestra serie no implica un peor pronóstico de las acrometástasis, especialmente si son únicas, por lo que es factible considerar opciones quirúrgicas como la resección amplia y reconstrucción." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Machado V, San-Julian M. Pronóstico y tratamiento de las acrometástasis: estudio observacional de 35 casos tratados en un único centro. Rev Esp Cir Ortop Traumatol. 2019;63:49–55." ] ] "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" => 1160 "Ancho" => 1639 "Tamanyo" => 162630 ] ] "descripcion" => array:1 [ "en" => "Plain X-ray (a) and MRI sequences T1 (b) and T2 (c), of a unique metastasis of hypernephroma in the calcaneus, in a 58-year-old male, treated by en bloc resection and reconstruction with structural allograft; (d) 5 years after surgery (e) the patient is able to walk several kilometres a day without needing crutches." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1826 "Ancho" => 1464 "Tamanyo" => 208469 ] ] "descripcion" => array:1 [ "en" => "Plain X-ray (a) and MRI (b) and PET (c) scans of a unique metastasis of lung adenocarcinoma in the first metacarpal, in a 35-year-old male, with no known primary prior to the diagnosis of metastasis, treated by en bloc resection (d) and reconstruction with autograft of the fibula (e and f). Two months afterwards the functionality of the hand is practically normal." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 421 "Ancho" => 1405 "Tamanyo" => 61601 ] ] "descripcion" => array:1 [ "en" => "Plain anteroposterior and lateral X-ray (a and b) and MRI (c) of a bone metastasis in the tibia, in a women of 45 years with breast cancer with multiple bone metastasis, treated with curettage, cryosurgery, cement fill and plate stabilisation (d); (e) 10 years after surgery the patient is able to undertake all her daily activities without outside help." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Single or multiple metastases<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Location of acrometastasis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Primary tumour \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tibia (proximal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Breast \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Talus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Calcaneus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Melanoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Calcaneus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Renal cell carcinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First metacarpal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tibia (middle third), talgus, calcaneus, 2 wedges, scaphoid, cuboid, 4 metatarsals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prostate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tibia (distal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lymphoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tibias (middle third) (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Renal cell carcinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First wedge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tibia (distal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bladder \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fibula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Colon \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ulna \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thyroid \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tibia (proximal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Myeloma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tibia (middle third) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Myeloma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Calcaneus, tibia (middle third) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adamantinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tibia (middle third) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unknown origin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Calcaneus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Endometrium \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tibia (middle third) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prostate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tibias (distal) (2) and radius \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neuroblastoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fourth metatarsal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Renal cell carcinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Radius \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lymphoma \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1936722.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Multiple bone or visceral metastases." ] ] ] "descripcion" => array:1 [ "en" => "Patients with unique or multiple metastases, location of the acrometastases per case and primary tumours responsible for the acrometastases." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (metastasis) <a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Primary \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Leeson et al.<a class="elsevierStyleCrossRef" href="#bib0110">1</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung (29.8%), breast (17.5%), kidney (14%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper limb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lower limb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(52) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Afshar et al.<a class="elsevierStyleCrossRef" href="#bib0150">9</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">221 patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung (34%), gastrointestinal (25%), kidney (10%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper limb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(221) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stomeo et al.<a class="elsevierStyleCrossRef" href="#bib0175">14</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper limb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung 34.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lower limb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung 28.6% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wu and Guise<a class="elsevierStyleCrossRef" href="#bib0180">15</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Breast (33%), lung (16.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper limb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Libson et al.<a class="elsevierStyleCrossRef" href="#bib0190">17</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper limb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">196 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung (47%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lower limb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Kidney (17%), colorectal (17%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Morris et al.<a class="elsevierStyleCrossRef" href="#bib0195">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper limb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung 40%, skin (30%), kidney (20%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Muñoz-Mahamud et al.<a class="elsevierStyleCrossRef" href="#bib0200">19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung (40%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper limb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1936723.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Multiple distal metastases in some patients." ] ] ] "descripcion" => array:1 [ "en" => "Literature references about primary tumours responsible for acrometastases." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Metastatic skeletal disease distal to the elbow and knee" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.C. Leeson" 1 => "J.T. Makley" 2 => "J.R. Carter" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Orthop" "fecha" => "1986" "volumen" => "206" "paginaInicial" => "94" "paginaFinal" => "99" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0115" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rare bone metastases of the olecranon" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Culleton" 1 => "E. de Sa" 2 => "M. Christakis" 3 => "M. Ford" 4 => "I. Zbieranowski" 5 => "E. 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Prognosis and treatment of acrometastases: Observational study of 35 cases treated in a single institution

Pronóstico y tratamiento de las acrometástasis: estudio observacional de 35 casos tratados en un único centro

V. Machado

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vmachado@unav.es

Corresponding author.

, M. San-Julian

Departamento de Cirugía Ortopédica y Traumatología, Clínica Universidad de Navarra, Pamplona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Bone metastases are the most common oncological process affecting the bones&#46; The axial skeleton is more frequently affected than the appendicular skeleton&#46; In all long bone involvement&#44; metastases distal to the elbow and knee&#44; or acrometastases&#44; are the least frequent&#59; comprising barely &#46;1&#37; and 7&#37; of all bone metastases&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1&#8211;5</span></a> In general&#44; the more distal the bone&#44; the less red bone marrow it contains&#44; and therefore its involvement is more rare&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The term &#8220;acrometastasis&#8221; is used indiscriminately in the literature to refer to &#8220;bone metastases in the distal regions of the extremities&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> or in some cases is only used for metastases affecting the wrist or the bones of the hands and feet&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8&#8211;11</span></a> However&#44; most articles define acrometastasis expressly as bone metastasis distal to the elbow and knee&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2&#44;4&#44;5&#44;12&#8211;14</span></a> as in our case&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A primary tumour of the lung has been described in the literature as most commonly causing acrometastasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;9&#44;12&#8211;15</span></a> However&#44; a primary in the kidney is the most common in some series on lower limb acrometastasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6&#44;7</span></a> The tibia is the bone most frequently affected by acrometastasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Involvement of the distal bones is considered a factor of poor prognosis&#44; since it implies wide disease spread&#46; The described mean survival is from 3 to 9 months from diagnosis of distal metastasis&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3&#44;6&#44;7&#44;9&#44;13&#44;14</span></a> with poor results for patients with no known primary tumour&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this study was to determine the most frequent location of acrometastases&#44; the primary tumour most commonly associated with metastases distal to the elbow and the knee&#44; and to assess the different surgical options for acrometastasis according to estimated patient survival&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We performed a retrospective study of patients with bone metastasis distal to the elbow and the knee&#44; diagnosed or treated in our centre&#39;s department of orthopaedic and trauma surgery from 1988 to 2016&#44; with a mean follow-up of 28 months &#40;3&#8211;121 months&#41;&#46; The treatment of each patient was individualised after the relevant multidisciplinary assessment&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Epidemiological variables and information were gathered about the primary tumour and the location of distal metastases&#44; number of metastases&#44; symptoms prior to diagnosis&#44; time between diagnosis of primary tumour and diagnosis of distal metastasis&#44; treatment of acrometastasis&#44; and survival time from diagnosis of the distal metastasis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using Fisher&#39;s exact test to compare proportions and Welch&#39;s test to compare means&#44; with STATA 12&#46;0 software&#44; considering <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 as statistically significant&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">Our series comprised 21 patients affected by bone metastases distal to the elbow and knee&#46; Seven patients had unique metastases and 14 had multiple metastases&#44; either bone or visceral&#46; There were a total of 35 acrometastases&#58; 4 in the upper limbs &#40;2 in the radius&#44; one in the ulna and one in the first metacarpal&#41;&#44; and 31 in the lower limbs &#40;13 in the tibia&#44; 5 in the calcaneus&#44; 5 in the wedges&#44; 2 in the talus&#44; one in the fibula&#44; one in the scaphoid&#44; and one in the cuboid&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The mean age of the patients was 48 &#40;range 8&#8211;74 years&#41;&#44; although the median was 55 years&#46; The distribution by sex shows a clear male predominance&#58; 14 men compared to 7 women&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The time between diagnosis of the primary tumour and diagnosis of acrometastasis was 41 months &#40;range 0&#8211;150&#41;&#46; Seven patients had no known primary tumour before diagnosis of acrometastasis&#59; 6 of them had a unique metastasis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; i&#46;e&#46;&#44; we found a statistically significant relationship between the onset of disease with distal bone metastasis and it being a unique metastasis&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The main symptom reported by patients was pain &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#44; 62&#37;&#41;&#59; 3 of these patients had a pathological fracture &#40;14&#37;&#41;&#46; Others consulted when they noticed a palpable mass &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#44; 14&#37;&#41;&#46; For the remainder &#40;24&#37;&#41; diagnosis was by extension studies since&#44; at the time of diagnosis&#44; the patients were asymptomatic&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The most common primary tumours were of the kidney &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3 patients&#59; 4 of the 35 acrometastases&#41; and the lung &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3 patients&#59; 3 of the 35 acrometastases&#41;&#46; Prostate carcinoma&#44; although only observed in 2 patients&#44; was responsible for 12 of the 35 acrometastases&#46; The other primary tumours are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The primary that most frequently caused distal metastases in the lower limb was hypernephroma &#40;19&#37;&#41;&#44; followed by adenocarcinoma of the lung &#40;13&#37;&#41;&#46; In the upper limb&#44; however&#44; a lung primary was the most common &#40;25&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The treatment received by patients was individualised in each case according to the location of the metastasis and especially the prognosis of the primary tumour&#44; the most frequent &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41; being en bloc resection plus reconstruction with autologous or heterologous structural graft &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Other options were cryosurgery and cement fill &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; intramedullary nail fixation &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; amputation &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; and surgical abstention &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Of the 21 patients&#44; 11 died &#40;52&#46;4&#37;&#41;&#44; 7 are alive with progressive disease&#44; and 3 with disease in remission&#46; Of the 11 patients who died&#44; 10 had multiple metastases&#46; The mean patient survival was 42 months &#40;1&#8211;121 months&#41;&#44; with no statistically significant differences between patients with unique metastases and those with multiple metastases &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;9&#41;&#44; although this might be due to the small sample size and the variety of patients included in the study&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">A diagnosis of metastasis distal to the elbow and knee poses a major challenge since&#44; because it is so rare is often not considered&#44; particularly when there is no known primary tumour&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1&#44;8&#44;10&#44;16</span></a> Acrometastases can be the first manifestation of an oncological process in up to 10&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">12&#44;14</span></a> In our series this percentage was higher &#40;33&#37;&#41;&#44; probably because we only included cases that had been diagnosed or treated in the orthopaedic and trauma surgery department&#44; without considering cases that had not been referred to us because surgical treatment had not been advised for them&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In our series&#44; as in other published series&#44; such as those of Baran&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> Lamarca&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> Mavrogenis<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> and Libson&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a> a location distal to the knee is more frequently associated with infradiaphragmatic tumours&#46; Specifically&#44; in our series&#44; hypernephroma was responsible for 19&#37; of the acrometastases of the lower limbs&#46; However&#44; metastases distal to the elbow are more often associated with supradiaphragmatic tumours&#44; such as the lung or thyroid&#46; Some publications that do not specify whether the acrometastasis affected an upper or a lower limb&#44; assert that the primary tumour most often associated with acrometastasis is that of the lung &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The treatment of distal metastases depends on the prognosis of the primary tumour&#59; therefore a multidisciplinary approach is essential&#46; Surgical treatment has a place beyond prophylactic osteosynthesis or amputation&#46; Although the literature refers to a poor prognosis&#44; we chose en bloc resection plus reconstruction with graft for most of our patients thanks to the multidisciplinary approach taken&#46; It is important to assess each case individually&#44; according to the number and location of the metastasis&#44; the response of the primary tumour to systemic treatments&#44; the patient&#39;s general condition and the functionality that might be achieved with surgery&#46; In short&#44; in the case of unique metastases from hypernephroma&#44; en bloc resection followed by reconstruction increases survival&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> Similarly&#44; in the case of breast cancer&#44; treatments should be planned that help not only to relieve pain&#44; but also to reduce tumour load and preserve limb function&#44; because these patients now have long survival&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Despite the fact that amputation is one of the most recommended surgical techniques in some series on bone metastases in the hands and feet&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3&#44;11&#44;21</span></a> it is not the only surgical option&#46; Although reasonable in the case of metastatic involvement of the phalanges&#44; it can cause great functional alteration if there is more proximal involvement&#46; Therefore&#44; and bearing in mind the survival observed in our series&#44; we do not consider amputation the technique of choice&#59; more conservative surgical treatment could be justified&#44; as long as they did not compromise the patient&#39;s prognosis&#44; although studies are required with a greater number of cases to confirm this&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Bone metastases distal to the elbow and knee do not necessary mean a poor prognosis&#44; especially when they are unique metastases&#46; In our series&#44; although 11 &#40;52&#37;&#41; of the patients died&#44; their mean survival was 42 months from diagnosis of the distal metastasis&#44; and this is 6 times higher than that described in the literature&#46; This is explained by the high number of unique metastases observed in our series&#44; which indicates less disease spread&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Given that these metastases are so rare compared to axial bone metastases&#44; the series we present is small&#44; and therefore the evidence provided is limited&#46; Furthermore&#44; our series includes 2 cases with bone metastasis in the proximal tibia&#44; which cannot be considered strictly acrometastases&#46; Another limitation of the study to consider is that only cases diagnosed or treated in the orthopaedic and trauma surgery department were included&#44; without considering the cases that the oncologist did not refer to our department&#44; and therefore there might be a bias in estimating the survival&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Level of evidence</span><p id="par0110" class="elsevierStylePara elsevierViewall">Level of evidence IV&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There is a degree of contradiction in the literature about the primary tumour that is most frequently associated with acrometastases&#44; as well as their prognosis and treatment&#46; The aim of this study is to determine the most frequent location of the acrometastases&#44; the most frequent primary tumour according to its location&#44; and to evaluate the surgical options according to the estimated survival&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study on patients diagnosed with acrometastases&#46; The primary tumour&#44; as well as the number&#44; location&#44; symptoms and treatment of the acrometastases and survival rate were collected&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">35 acrometastases in 21 patients were reviewed&#58; 4 in the upper limbs and 31 in the lower limbs&#59; the tibia was the most frequently affected bone &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&#46; The primary tumour that most frequently produced acrometastases in the lower limb was hypernephroma &#40;19&#37;&#41;&#46; In the upper limb lung tumour was more frequent &#40;25&#37;&#41;&#46; Eleven patients died &#40;52&#37;&#41;&#59; 10 of them had concomitant multiple metastases&#46; The mean survival was 42 months from the diagnosis of acrometastases&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Acrometastases are more frequently seen in the lower extremities and the most frequent tumour was hypernephroma followed by lung&#46; The treatment of acrometastases depends on the prognosis of the primary tumour&#44; so a multidisciplinary approach is essential&#46; The mean survival in our series did not imply a poorer prognosis for acrometastases&#44; so it is feasible to consider surgical options such as wide resection and reconstruction&#46; A unique acrometastases is a good prognosis signal&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Existe cierta contradicci&#243;n en la literatura acerca del tumor primario que se asocia con m&#225;s frecuencia a las acromet&#225;stasis&#44; as&#237; como acerca de su pron&#243;stico y tratamiento&#46; El objetivo de nuestro trabajo es determinar la localizaci&#243;n m&#225;s frecuente de las acromet&#225;stasis&#44; el tumor primario m&#225;s frecuente seg&#250;n su localizaci&#243;n y evaluar las opciones quir&#250;rgicas en funci&#243;n de la supervivencia estimada&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Hemos realizado un estudio retrospectivo de los pacientes diagnosticados de acromet&#225;stasis en nuestra instituci&#243;n&#46; Se recogieron variables epidemiol&#243;gicas&#44; as&#237; como informaci&#243;n acerca de tumor primario y n&#250;mero&#44; localizaci&#243;n&#44; s&#237;ntomas y tratamiento de las acromet&#225;stasis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Se revisaron 35 acromet&#225;stasis en 21 pacientes&#58; 4 en miembros superiores y 31 en miembros inferiores&#44; siendo la tibia el hueso m&#225;s frecuentemente afectado &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&#46; El tumor primario que con m&#225;s frecuencia produce acromet&#225;stasis en miembros inferiores es el hipernefroma &#40;19&#37;&#41;&#59; en los miembros superiores&#44; sin embargo&#44; el pulm&#243;n fue m&#225;s frecuente &#40;25&#37;&#41;&#46; Once pacientes fallecieron &#40;52&#37;&#41;&#44; de los cuales 10 ten&#237;an met&#225;stasis en m&#250;ltiples localizaciones&#46; La media de supervivencia fue de 42 meses desde el diagn&#243;stico de las acromet&#225;stasis&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Las acromet&#225;stasis se observan con m&#225;s frecuencia en las extremidades inferiores&#44; y el tumor primario m&#225;s frecuente es el hipernefroma&#44; seguido del de pulm&#243;n&#46; El tratamiento de las acromet&#225;stasis depende del pron&#243;stico del paciente&#44; por lo que es esencial un abordaje multidisciplinar&#46; La media de supervivencia en nuestra serie no implica un peor pron&#243;stico de las acromet&#225;stasis&#44; especialmente si son &#250;nicas&#44; por lo que es factible considerar opciones quir&#250;rgicas como la resecci&#243;n amplia y reconstrucci&#243;n&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Machado V&#44; San-Julian M&#46; Pron&#243;stico y tratamiento de las acromet&#225;stasis&#58; estudio observacional de 35 casos tratados en un &#250;nico centro&#46; Rev Esp Cir Ortop Traumatol&#46; 2019&#59;63&#58;49&#8211;55&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1160
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            "Tamanyo" => 162630
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Plain X-ray &#40;a&#41; and MRI sequences T1 &#40;b&#41; and T2 &#40;c&#41;&#44; of a unique metastasis of hypernephroma in the calcaneus&#44; in a 58-year-old male&#44; treated by en bloc resection and reconstruction with structural allograft&#59; &#40;d&#41; 5 years after surgery &#40;e&#41; the patient is able to walk several kilometres a day without needing crutches&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1826
            "Ancho" => 1464
            "Tamanyo" => 208469
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Plain X-ray &#40;a&#41; and MRI &#40;b&#41; and PET &#40;c&#41; scans of a unique metastasis of lung adenocarcinoma in the first metacarpal&#44; in a 35-year-old male&#44; with no known primary prior to the diagnosis of metastasis&#44; treated by en bloc resection &#40;d&#41; and reconstruction with autograft of the fibula &#40;e and f&#41;&#46; Two months afterwards the functionality of the hand is practically normal&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 421
            "Ancho" => 1405
            "Tamanyo" => 61601
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Plain anteroposterior and lateral X-ray &#40;a and b&#41; and MRI &#40;c&#41; of a bone metastasis in the tibia&#44; in a women of 45 years with breast cancer with multiple bone metastasis&#44; treated with curettage&#44; cryosurgery&#44; cement fill and plate stabilisation &#40;d&#41;&#59; &#40;e&#41; 10 years after surgery the patient is able to undertake all her daily activities without outside help&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Single or multiple metastases<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Location of acrometastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Primary tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tibia &#40;proximal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Talus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Calcaneus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Calcaneus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Renal cell carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First metacarpal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tibia &#40;middle third&#41;&#44; talgus&#44; calcaneus&#44; 2 wedges&#44; scaphoid&#44; cuboid&#44; 4 metatarsals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prostate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tibia &#40;distal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tibias &#40;middle third&#41; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Renal cell carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First wedge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tibia &#40;distal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fibula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Colon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulna&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Thyroid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tibia &#40;proximal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Myeloma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tibia &#40;middle third&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Myeloma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Calcaneus&#44; tibia &#40;middle third&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adamantinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tibia &#40;middle third&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unknown origin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Calcaneus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Endometrium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tibia &#40;middle third&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prostate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tibias &#40;distal&#41; &#40;2&#41; and radius&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuroblastoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fourth metatarsal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Renal cell carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radius&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;metastasis&#41; <a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Primary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Leeson et al&#46;</span><a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung &#40;29&#46;8&#37;&#41;&#44; breast &#40;17&#46;5&#37;&#41;&#44; kidney &#40;14&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Upper limb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lower limb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Afshar et al&#46;</span><a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">221 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung &#40;34&#37;&#41;&#44; gastrointestinal &#40;25&#37;&#41;&#44; kidney &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Upper limb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;221&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Stomeo et al&#46;</span><a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Upper limb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung 34&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lower limb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung 28&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Wu and Guise</span><a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Breast &#40;33&#37;&#41;&#44; lung &#40;16&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Upper limb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Libson et al&#46;</span><a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Upper limb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">196&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung &#40;47&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lower limb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney &#40;17&#37;&#41;&#44; colorectal &#40;17&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Morris et al&#46;</span><a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Upper limb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung 40&#37;&#44; skin &#40;30&#37;&#41;&#44; kidney &#40;20&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mu&#241;oz-Mahamud et al</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung &#40;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Upper limb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                    0 => array:2 [
                      "titulo" => "Metastatic skeletal disease distal to the elbow and knee"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;C&#46; Leeson"
                            1 => "J&#46;T&#46; Makley"
                            2 => "J&#46;R&#46; Carter"
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                    0 => array:1 [
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                        "tituloSerie" => "Clin Orthop"
                        "fecha" => "1986"
                        "volumen" => "206"
                        "paginaInicial" => "94"
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                      ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rare bone metastases of the olecranon"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Culleton"
                            1 => "E&#46; de Sa"
                            2 => "M&#46; Christakis"
                            3 => "M&#46; Ford"
                            4 => "I&#46; Zbieranowski"
                            5 => "E&#46; Sinclair"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Palliative Med"
                        "fecha" => "2008"
                        "volumen" => "11"
                        "paginaInicial" => "1088"
                        "paginaFinal" => "1091"
                      ]
                    ]
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Metastases to rare locations as the initial manifestation of non-small cell lung cancer&#58; two case reports"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Lozi&#263;"
                            1 => "Z&#46; Silconi"
                            2 => "N&#46; Misljenovi&#263;"
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                    ]
                  ]
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                        "tituloSerie" => "Coll Antropol"
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                        "paginaInicial" => "609"
                        "paginaFinal" => "612"
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                            "web" => "Medline"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Bronchogenic squamous cell carcinoma with soft-tissue metastasis to the hand&#58; an unusual case presentation and review of the literature"
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                          "autores" => array:5 [
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                            3 => "K&#46;G&#46; Lindsey"
                            4 => "L&#46;R&#46; Leddy"
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                      "titulo" => "Tibial involvement in breast cancer&#58; issues in diagnosis and management"
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                          "autores" => array:6 [
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Article information

ISSN: 19888856
Original language: English

DOI:10.1016/j.recote.2018.11.005

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Year/Month	Html	Pdf	Total

2024 November	4	0	4
2024 October	37	10	47
2024 September	71	20	91
2024 August	53	15	68
2024 July	48	14	62
2024 June	42	10	52
2024 May	21	4	25
2024 April	33	7	40
2024 March	54	5	59
2024 February	16	9	25
2024 January	53	4	57
2023 December	52	7	59
2023 November	49	11	60
2023 October	80	11	91
2023 September	47	0	47
2023 August	35	4	39
2023 July	51	5	56
2023 June	42	2	44
2023 May	42	4	46
2023 April	62	5	67
2023 March	38	3	41
2023 February	55	2	57
2023 January	52	3	55
2022 December	55	8	63
2022 November	35	10	45
2022 October	32	24	56
2022 September	47	11	58
2022 August	60	8	68
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2021 December	55	12	67
2021 November	55	8	63
2021 October	38	17	55
2021 September	55	5	60
2021 August	63	7	70
2021 July	46	12	58
2021 June	35	2	37
2021 May	42	9	51
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