Clinical note
A case of brain and leptomeningeal metastases from urothelial carcinoma of the bladder
Un caso de metástasis cerebrales y leptomeníngeas de un carcinoma urotelial de vejiga
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(A) Maximum intensity projection image: decreased number, size and metabolic activity of metastatic lymph nodes, numerous skin metastases at the root of the left thigh (black arrows) and right pleural carcinomatosis (white arrow). The left uretero-pyelectasis has been solved. (B) CT of the PET/CT and fusion PET/CT chest image showing hypermetabolic thickening of the thoracic pleura at the middle lobe (white arrow) associated with pleural effusion. (C) Image of fusion PET/CT: detail of the numerous hypermetabolic skin lesions on the root of the left thigh (white arrows). Increased edema of the left thigh.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Banzo, M.A. Ubieto, A. Andrés, L. Tardín, E.F. Rambalde, L.F. Cancer, P. Razola, E. Prats" "autores" => array:8 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Banzo" ] 1 => array:2 [ "nombre" => "M.A." "apellidos" => "Ubieto" ] 2 => array:2 [ "nombre" => "A." 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"apellidos" => "Prats" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808914001062?idApp=UINPBA00004N" "url" => "/22538089/0000003300000005/v1_201408200020/S2253808914001062/v1_201408200020/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2253808914001074" "issn" => "22538089" "doi" => "10.1016/j.remnie.2014.06.018" "estado" => "S300" "fechaPublicacion" => "2014-09-01" "aid" => "610" "copyright" => "Elsevier España, S.L.U. and SEMNIM" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Rev Esp Med Nucl Imagen Mol. 2014;33:286-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 361 "formatos" => array:2 [ "HTML" => 228 "PDF" => 133 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Evaluation of physiological FDG uptake in the skeleton in adults: Is it uniformly distributed?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "286" "paginaFinal" => "289" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación de la captación fisiológica de FDG en el esqueleto en adultos: ¿Está uniformemente distribuida?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1840 "Ancho" => 3257 "Tamanyo" => 257118 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The relationship between bone marrow SUVmax and age for both sexes (<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−0.25; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Mustafa Aras, Fuat Dede, Tunc Ones, Sabahat Inanır, Tanju Yusuf Erdıl, Halil Turgut Turoglu" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Mustafa" "apellidos" => "Aras" ] 1 => array:2 [ "nombre" => "Fuat" "apellidos" => "Dede" ] 2 => array:2 [ "nombre" => "Tunc" "apellidos" => "Ones" ] 3 => array:2 [ "nombre" => "Sabahat" "apellidos" => "Inanır" ] 4 => array:2 [ "nombre" => "Tanju Yusuf" "apellidos" => "Erdıl" ] 5 => array:2 [ "nombre" => "Halil Turgut" "apellidos" => "Turoglu" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808914001074?idApp=UINPBA00004N" "url" => "/22538089/0000003300000005/v1_201408200020/S2253808914001074/v1_201408200020/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical note</span>" "titulo" => "A case of brain and leptomeningeal metastases from urothelial carcinoma of the bladder" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "290" "paginaFinal" => "292" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Erhamamcı, M. Reyhan, N. Altinkaya" "autores" => array:3 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Erhamamcı" "email" => array:1 [ 0 => "sevaler@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Reyhan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "N." "apellidos" => "Altinkaya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Nuclear Medicine, Faculty of Medicine, Baskent University, Ankara, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Radiology, Faculty of Medicine, Baskent University, Ankara, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Un caso de metástasis cerebrales y leptomeníngeas de un carcinoma urotelial de vejiga" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2336 "Ancho" => 3000 "Tamanyo" => 285444 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Maximum intensity projection (MIP) (A), sagittal MIP (B), transaxial PET (C, D) and coronal PET (E, F) images showed two lesions with increased metabolic activity in the right parieto-occipital region of brain (arrows). Physiologic accumulation of excreted FDG in the orthotopic ileal neobladder was confirmed by postvoid MIP images of pelvis (G) (arrow). Focal FDG uptake in the right iliac region was considered to be due to metallic material placed after surgery. However, no other abnormal FDG uptake was observed elsewhere in the body.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Urothelial carcinoma of the bladder (UCB) constitutes the majority of bladder carcinomas and usually gives metastases to lymph nodes, liver, lung, bones, adrenal gland and intestine.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Brain metastases are relatively infrequent, but are often seen during chemotherapy in the advanced stage of bladder carcinoma, reported incidences 1–8%.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> However, leptomeningeal metastases are a very rare entity, reported only in case reports in bladder carcinoma. Leptomeningeal metastases occur in 1–8% of all cancer patients and inevitably have a fatal outcome.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The staging of UCB is an essential step in appropriate management of disease. Currently the staging assessment of UCB is mainly based on imaging techniques such as CT and MRI, with contrast enhancement, both of which are recommended by current guidelines. These techniques are mainly based on morphological estimates such as size and shape of enlarged lymph node, and therefore are not sufficient to detect small metastases.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> As a metabolic and anatomic diagnostic tool, FDG PET/CT has the ability to overcome the limitations of conventional imaging modalities leading to changes in patient management.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–10</span></a> FDG PET/CT provides important diagnostic information on the location, extent, and metabolic characteristics of recurrent and metastatic bladder UCB lesions.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Here, we have presented a case of a 45-year-old man with a rare brain metastases as the first metastatic manifestation secondary to UCB followed by leptomeningeal metastases without any other organ involvement and discussed the imaging modalities.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 45-year-old man, smoker of 20 cigarettes/day during 22 year, was admitted to the hospital due to macroscopic hematuria. Urine cytology was negative. Abdominal MRI demonstrated a mass lesion on the right lateral wall of urinary bladder. Cystoscopic examination revealed thickening in the right lateral wall of the urinary bladder. Transurethral resection of the bladder tumor (TUR-Bt) was performed. Pathological examination of the TUR material revealed a high-grade UCB, pT2, G3, with foci of neuroendocrine carcinoma. The metastatic workup, including physical examination, laboratory and radiographic studies did not reveal any remarkable abnormalities. Body CT and bone scans demonstrated no evidence of metastases elsewhere in the body. The tumor was staged as T2N0M0. The patient received 4 cycles of neoadjuvant chemotherapy with gemcitabine-cisplatin. A check on cystoscopy 6 months after treatment showed evidence of tumor recurrence. The patient underwent a cystoprostatectomy with an orthotopic ileal neobladder and bilateral pelvic lymph node dissection. Histopathological examination indicated a high-grade UCB (T2N0M0).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Five months after cystoprostatectomy, the patient readmitted because of the dizziness, nausea and loss of balance. Brain MRI revealed a mass lesion located at right parieto-occipital region (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Five days later, FDG PET/CT images for the restaging showed two lesions with increased metabolic activity in the right parieto-occipital region of brain (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). No other abnormal FDG uptake was detected elsewhere in the body. The patient underwent craniectomy and excisional biopsy. Histopathology demonstrated the cerebral lesion to be a metastatic urothelial carcinoma. On the basis of these finding, the patient was diagnosed as having brain metastases from UCB.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was started whole brain radiotherapy. Two months later, in the last week of radiotherapy, the patient complained of weakness in the bilaterally upper and lower extremity, urinary and fecal incontinence. On neurological examination revealed paresis in the bilaterally upper and lower extremity. MRI with contrast administration showed diffuse leptomeningeal enhancement consistent with metastatic leptomeningeal disease (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). A lumbar puncture was performed and with pathological analysis of the cerebrospinal fluid was negative for tumor cells, with increased protein concentration, and decreased glucose concentration. Leptomeningeal metastases were diagnosed with positive imaging, strict neurological symptoms and signs, although cytology was negative.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Systemic chemotherapy as well as palliative radiotherapy of the brain and spinal cord was begun despite a poor prognosis. However, our patient's condition gradually worsened, and he died 3 months after the diagnosis of leptomeningeal metastases.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">In recent years, the improved radiological techniques and multi-therapeutic approaches to bladder cancer have prolonged the survival period but at the same time increased the risk for developing uncommon metastatic lesions, such as brain and leptomeningeal metastases. Usually, the development of brain and leptomeningeal metastases is a late event in the course of bladder carcinoma, occurs most often in patients with extensive systemic disease and have a bad prognosis despite aggressive therapy. Brain or leptomeningeal metastases as the first metastatic manifestation of UCB without evidence of recurrent or disseminated disease is extremely rare, with few cases reported in the literature.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Noninvasive imaging plays a pivotal role in the staging and restaging of bladder cancer. Currently, staging of patients with UCB depends on CT or MRI to detect metastatic disease; however, these have limited accuracy, and thus imaging methods with improved accuracy are clearly needed.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In recent years, PET/CT has been proposed as a noninvasive imaging modality based on functional molecular or metabolic, rather than morphologic, criteria that may help to overcome some of the problems of CT and MRI imaging.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–10</span></a> Often the metabolic changes detectable by PET precede morphologic changes detectable by anatomic imaging methods, leading to greater sensitivity of PET. PET/CT is specific for urothelial carcinoma metastases, is more sensitive than standard CT, and is allowing for complete tumor staging in single examination.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> In the present case, two lesions in the brain were detected by FDG PET/CT while only one lesion was revealed by MRI. Reason for the failure to identify the second lesion by MRI is that lesion may be metabolically activated, but not be developed anatomically yet. Different intensity FDG uptake of two metastatic lesions can be explained by different differentiation degree. As no evidence of metastases was detected elsewhere in the body except in the brain, treatment was planed as only whole brain radiotherapy.</p><p id="par0050" class="elsevierStylePara elsevierViewall">FDG PET/CT has been used with limited success in primary diagnosis and locoregional staging of urinary bladder cancer, mainly due to the presence of excreted FDG in the urinary tract, which often masks the urinary bladder lesion and probably the adjacent lymph nodes.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> To overcome these limitations, some investigators have attempted to achieve washing out the excreted FDG by using postvoid delayed imaging, diuresis, fluid loading or bladder catherization.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Recent efforts with PET/CT have focused on alternate PET tracer in bladder cancer staging, such as <span class="elsevierStyleSup">11</span>C-acetate, <span class="elsevierStyleSup">11</span>C-choline and <span class="elsevierStyleSup">11</span>C-methionine.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Whether tracer other than FDG can have a role in the imaging evaluation of patients with UCB requires additional experience.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> For this reason, FDG PET/CT has not been useful in local staging but have a role in detection of nodal and distant metastases.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Diagnosis of leptomeningeal metastases is based on contrast-enhancement MRI and the detection of carcinomatous cells by the cytological examination of the cerebrospinal fluid. However, in the initial lumbar puncture a positive cytology is found in only 50% of patients with neoplastic meningitis. Although cytology was negative in our patient, diagnosis of leptomeningeal metastases was certain because of typical symptoms, neurological signs and apparent MRI findings.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Surgical excision followed by brain radiotherapy has been considered the mainstay treatment for brain metastases. However, the overall survival is very poor, being between 2 and 7 months.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> In the last week of radiotherapy, the patient developed leptomeningeal metastases. The specific treatment of leptomeningeal metastases is aimed toward palliation, preventing further neurological deterioration, and improving survival. However, the median survival is 38 days (range, 6–270 days).<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Our patient died 3 months after the diagnosis of leptomeningeal metastases, consistent with the data reported in the literature.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres362362" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec342052" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres362363" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec342053" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-07-19" "fechaAceptado" => "2013-10-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec342052" "palabras" => array:5 [ 0 => "Urothelial bladder carcinoma" 1 => "Brain metastases" 2 => "Leptomeningeal metastases" 3 => "FDG" 4 => "PET/CT" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec342053" "palabras" => array:5 [ 0 => "Carcinoma urotelial de vejiga" 1 => "Metástasis cerebral" 2 => "Metástasis leptomeníngea" 3 => "FDG" 4 => "PET/TC" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Brain metastases are unusual from urethelial carcinoma of bladder and particularly the occurrence of leptomeningeal metastases is extremely rare, with few cases described in the literature. We present a case of a 45-year-old man with a rare brain metastases as the first metastatic manifestation secondary to urethelial carcinoma of bladder followed by leptomeningeal metastases without any other organ involvement. Eleven months after the diagnosis of high-grade urethelial carcinoma of bladder (T2N0M0), the patient was detected having brain metastases by MRI. FDG PET/CT images for the metastatic evaluation showed no abnormal FDG uptake elsewhere in the body except the brain. Histopathology examination from brain lesion demonstrated the cerebral lesion to be a metastatic urothelial carcinoma. Two months later, the patient was diagnosed to have leptomeningeal metastases by MRI. Our patient's condition gradually worsened, and he died 3 months after the diagnosis of leptomeningeal metastases.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las metástasis cerebrales del carcinoma urotelial de vejiga son poco habituales y, en particular, las metástasis leptomeníngeas son extremadamente raras, siendo pocos los casos descritos en la literatura. Presentamos un hombre de 45 años con metástasis cerebral como primera manifestación secundaria de un carcinoma urotelial de vejiga seguido de metástasis leptomeníngeas sin otra afectación sistémica. Once meses después del diagnóstico de un carcinoma urotelial de vejiga (T2N0M0), se detectaron metástasis cerebrales por RM. El estudio de estadificación con FDG PET/TC no demostró captación anormal en otra parte del cuerpo a excepción del cerebro. El examen histopatológico de una lesión cerebral demostró metástasis del carcinoma urotelial. Dos meses después, una RM descubrió metástasis leptomeníngeas. La situación clínica del paciente se deterioró gradualmente, y falleció 3 meses después del diagnóstico de las metástasis leptomeníngeas.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1024 "Ancho" => 950 "Tamanyo" => 67756 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Postcontrast axial T1-weighted MRI of the brain showing a hyperintense lesion with surrounding edema (arrow) in the right parieto-occipital region.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2336 "Ancho" => 3000 "Tamanyo" => 285444 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Maximum intensity projection (MIP) (A), sagittal MIP (B), transaxial PET (C, D) and coronal PET (E, F) images showed two lesions with increased metabolic activity in the right parieto-occipital region of brain (arrows). Physiologic accumulation of excreted FDG in the orthotopic ileal neobladder was confirmed by postvoid MIP images of pelvis (G) (arrow). Focal FDG uptake in the right iliac region was considered to be due to metallic material placed after surgery. However, no other abnormal FDG uptake was observed elsewhere in the body.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 889 "Ancho" => 950 "Tamanyo" => 88758 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Postcontrast sagittal T1-weighted MRI of the cervical spine showing diffuse leptomeningeal infiltration (arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Urothelial tumors of the bladder" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2019 July | 0 | 2 | 2 |
| 2019 April | 0 | 1 | 1 |
| 2019 January | 0 | 1 | 1 |
| 2018 November | 0 | 1 | 1 |
| 2018 February | 2 | 8 | 10 |
| 2018 January | 5 | 5 | 10 |
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| 2017 November | 6 | 1 | 7 |
| 2017 October | 7 | 3 | 10 |
| 2017 September | 6 | 4 | 10 |
| 2017 August | 12 | 3 | 15 |
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| 2017 June | 14 | 9 | 23 |
| 2017 May | 11 | 3 | 14 |
| 2017 April | 14 | 4 | 18 |
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| 2017 February | 10 | 1 | 11 |
| 2017 January | 12 | 6 | 18 |
| 2016 December | 8 | 7 | 15 |
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| 2016 October | 21 | 9 | 30 |
| 2016 September | 15 | 4 | 19 |
| 2016 August | 0 | 3 | 3 |
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| 2016 June | 0 | 9 | 9 |
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| 2016 March | 0 | 2 | 2 |
| 2016 February | 0 | 2 | 2 |
| 2016 January | 3 | 3 | 6 |
| 2015 December | 10 | 3 | 13 |
| 2015 November | 11 | 3 | 14 |
| 2015 October | 15 | 6 | 21 |
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| 2015 March | 4 | 0 | 4 |
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