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Original Article
Breast cancer lymphoscintigraphy: Factors associated with sentinel lymph node non visualization
Linfogammagrafía en el cáncer de mama: factores asociados con la no visualización del ganglio centinela
S.C. Vaza,
Corresponding author
sofiacarrilhovaz@gmail.com

Corresponding author.
, Â. Silvaa, R. Sousaa, T.C. Ferreiraa, S. Estevesb, I.P. Carvalhoa, P. Ratãoa, A. Daniela, L. Salgadoa
a Department of Nuclear Medicine of Portuguese Institute of Oncology, Lisbon Center, Portugal
b Clinical Research Unit of Portuguese Institute of Oncology, Lisbon Center, Portugal
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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">It is widely accepted that sentinel lymph node &#40;SLN&#41; biopsy is an important procedure for the correct staging of patients with breast cancer&#46; Furthermore&#44; SLN biopsy allows a minimally invasive surgery&#44; reducing the co-morbidities associated with axillary lymph node dissection&#46; Lymphoscintigraphy is a simple and accurate method that helps identifying the sentinel lymph node&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In a minority of cases lymphoscintigraphic detection of SLN is not possible&#46; Failure to visualize a SLN increases the difficulty of surgical intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#44;4</span></a> In some patients the hidden SLN will be intra-operatively detected&#44; either by gamma-probe alone or by gamma-probe combined with blue dye&#46; When SLN is not found&#44; axillary lymph node dissection is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Some authors argue that the main reason for SLN non identification is SLN metastization because lymphatics may be blocked by cancer cells&#44; not allowing colloid progression through lymphatic channels&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1&#44;6</span></a> On the other hand&#44; there are studies that did not find significant association between negative lymphoscintigraphy and axillary metastases&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> During the past decade several other factors have been reported as being related to the failure of SLN identification in lymphoscintigraphy&#44; namely&#44; patient&#39;s age and body mass index &#40;BMI&#41;&#44; as well as tumor characteristics&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In our tertiary cancer center we perform around 570 lymphoscintigraphies in breast cancer patients per year&#46; The scintigraphic SLN identification rate in our department is 98&#37; and the concordance of SLN detection both in lymphoscintigraphy and surgery is 95&#37;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The primary goal of this retrospective study was to analyze which factors could influence the lymphoscintigraphic SLN non identification and to study each factor separately&#46; As a secondary analysis&#44; we wanted to establish the relationship between lymphoscintigraphic failure in detecting the SLN and the existence of SLN metastases&#44; by controlling for the previously defined variables that could influence the examination result&#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 reviewed all lymphoscintigraphies performed in breast cancer patients between January 2010 and December 2013&#44; corresponding to a total of 2200 examinations&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Lymphoscintigraphy was classified as&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Positive lymphoscintigraphy &#40;PL&#41; &#8211; lymphoscintigraphy with SLN identification&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Negative lymphoscintigraphy &#40;NL&#41; &#8211; lymphoscintigraphy without SLN identification&#46;</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">During this period we found 40 NL and from the remaining large amount of PL&#44; we only included 184 PL in our study&#46; The PL group was considered as a &#8220;control group&#8221; and corresponded to all patients with SLN identification in lymphoscintigraphy consecutively performed between January and June 2011&#46; This period was randomly selected&#44; because the technique was similar between 2010 and 2013&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Inclusion and exclusion criteria&#58;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We included all female patients&#44; with unilateral breast carcinoma and without previous chemotherapy that performed lymphoscintigraphy in our department&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Lymphoscintigraphy was performed in patients with histological confirmation of invasive carcinoma or <span class="elsevierStyleItalic">in situ</span> carcinoma with high or intermediate grade&#44; necrosis or other aggressive characteristics and that had no histological evidence of axillary metastases&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1&#44;3&#44;7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Our study excluded patients with bilateral breast cancer&#44; male patients and patients treated with neoadjuvant chemotherapy prior to lymphoscintigraphy&#44; due to the small number of patients in these groups&#46; We wanted to have a homogenous study group&#44; avoiding extra factors that could influence the results&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Patients with very early stage breast cancer &#40;low-grade ductal carcinoma <span class="elsevierStyleItalic">in situ</span>&#41; who were not proposed to mastectomy&#44; inflammatory breast cancer&#44; histologically confirmed positive axillary or extra-axillary lymph nodes or patients with widespread metastases beyond surgical resection did not perform lymphoscintigraphy&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Lymphoscintigraphy and surgical technique of the sentinel lymph node&#58;</p><p id="par0085" class="elsevierStylePara elsevierViewall">All examinations were performed in our department using a subareolar injection of 55&#46;5<span class="elsevierStyleHsp" style=""></span>MBq &#40;1&#46;5<span class="elsevierStyleHsp" style=""></span>mCi&#41; of <span class="elsevierStyleSup">99m</span>Tc-albumin nanocolloid&#44; 0&#46;5<span class="elsevierStyleHsp" style=""></span>mL&#44; in the same quadrant of the breast lesion&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Immediately after the injection sequential anterior&#44; lateral and antero-oblique planar images&#44; with the patient in supine position&#44; were acquired using a dual-head Siemens E&#46; Cam<span class="elsevierStyleSup">&#174;</span> or Philips Brightview<span class="elsevierStyleSup">&#174;</span> gamma-cameras with low-energy and high-resolution collimators&#46; The first axillary hotspot identified in the lymphoscintigraphic image was considered the SLN and its projection was marked in the skin using a point source of <span class="elsevierStyleSup">99m</span>Tc and further confirmed with a gamma-probe &#40;Eurorad Europrobe<span class="elsevierStyleSup">&#174;</span>&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">When SLN was identified in lymphoscintigraphy&#44; it was considered PL&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">When the SLN was not visible in the first set of images&#44; patients were encouraged to do breast massage and image acquisition was sequentially repeated until up to 4<span class="elsevierStyleHsp" style=""></span>h after injection&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In our department we did not inject a second dose of radiopharmaceutical because of time and logistic aspects&#46; In the period of time included in our study we did not have SPECT&#47;CT available&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">When SLN was not identified in lymphoscintigraphy&#44; it was considered NL&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Usually&#44; lymphoscintigraphy and surgery took place on the same day&#46; In the operating room and after anesthesia&#44; the surgeon injected blue dye in the upper-external breast quadrant&#46; SLN biopsy was guided by our cutaneous mark and the removed SLN was the lymph node with highest counts shown by the gamma-probe &#40;Eurorad Europrobe<span class="elsevierStyleSup">&#174;</span>&#41;&#44; the majority marked with blue dye&#46; Occasionally&#44; more than one lymph node was resected&#44; namely when there were other lymph nodes with &#62;10&#37; of the SLN greatest activity and when clinically suspicious lymph nodes were found&#46; The lymph nodes removed were measured with gamma detector probe to confirm that they were responsible for the activity detected during lymphoscintigraphy and surgery&#46; After resection&#44; the axillary region was explored with the gamma-probe to confirm that there was only residual radioactivity&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The SLN was separated and carefully identified&#44; putted in formal and sent to the Department of Pathology&#44; where the SLN protocol was performed&#46; First a macroscopic study of the lymph node was made&#44; then it was sliced following the longitudinal&#47;vertical axis into approximately 2<span class="elsevierStyleHsp" style=""></span>mm serial sections&#46; Afterwards the lymph node was fixed in paraffin blocks&#46; Three-micro sections of each block were obtained&#44; stained with hematoxylin&#8211;eosin and finally examined under the microscope&#46; Immunohistochemical study was used in dubious cases&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Parameters analyzed&#58;</p><p id="par0130" class="elsevierStylePara elsevierViewall">We retrospectively collected information from the patients&#8217; medical records concerning the factors referred in the literature as being associated with SLN identification failure in lymphoscintigraphy&#46; The seven factors included in our study and the parameters analyzed for each factor&#44; were&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0135" class="elsevierStylePara elsevierViewall">patient age&#58; &#60;60 <span class="elsevierStyleItalic">vs&#46;</span> &#8805;60 years-old&#59;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0140" class="elsevierStylePara elsevierViewall">body mass index &#40;BMI&#41;&#58; &#60;30 <span class="elsevierStyleItalic">vs&#46;</span> &#8805;30&#59;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0145" class="elsevierStylePara elsevierViewall">breast carcinoma size according to AJCC Cancer Staging Manual&#44; 7th edition classification<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a>&#58; T1a&#47;b&#47;c&#47;mi&#44; T2 or T3&#59;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;4&#41;</span><p id="par0150" class="elsevierStylePara elsevierViewall">histologic type according to AJCC Cancer Staging Manual&#44; 7th edition classification<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a>&#58; invasive ductal carcinoma &#40;IDC&#41;&#44; intermediate or high grade ductal carcinoma <span class="elsevierStyleItalic">in situ</span> &#40;DCIS G2&#47;G3&#41; or invasive carcinoma&#59;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#40;5&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">breast tumor localization&#58; external quadrants&#44; internal quadrants or other&#59;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#40;6&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">pre-operative hookwire marking of the breast lesion before lymphoscintigraphy&#58; yes or no&#59;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#40;7&#41;</span><p id="par0165" class="elsevierStylePara elsevierViewall">SLN metastases &#40;both macro and micrometastases were considered SLN metastization&#41;&#58; yes or no&#46;</p></li></ul></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0170" class="elsevierStylePara elsevierViewall">Clinical and demographic characterization was performed using descriptive statistics&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">We tested for any association between SLN non detection in lymphoscintigraphy and all the factors previously mentioned by using both univariate and multivariate logistic regression&#46; Multivariate analysis considered all factors for which an association with SLN non detection was identified in univariate analysis &#40;<span class="elsevierStyleItalic">p</span>-value below 0&#46;10 in the likelihood ratio test&#41;&#46; In the secondary analysis&#44; in which the predictor of main interest was SLN metastases&#44; the association with SLN non detection in lymphoscintigraphy was evaluated adjusting for all relevant factors identified in the previous analysis&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">To compare the SLN metastization in the group of cases and in the group of controls&#44; we also conducted a matched pairs analysis by matching each case with two control subjects of similar age &#40;&#60;60 <span class="elsevierStyleItalic">vs&#46;</span> &#8805;60 years old&#41; and BMI &#40;&#60;30 <span class="elsevierStyleItalic">vs&#46;</span> &#8805;30&#41;&#46; Matching was performed using random selection methods and was done by a third person who was blinded to the SLN metastatic status of the patients in the control group&#46; The matched samples were then compared using Mantel&#8211;Haenszel method for multiple matched controls per case&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Statistical significance was assessed by two-tailed tests with an alpha level of 0&#46;05&#44; unless otherwise specified&#46; All of the analysis were done with R software&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0190" class="elsevierStylePara elsevierViewall">The study included 40 patients with negative lymphoscintigraphy and 184 patients with positive lymphoscintigraphy &#40;SLN non detection rate was 2&#37; in lymphoscintigraphy&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In spite of the different number of patients included in each group&#44; both groups were similar in terms of BMI&#44; tumor size&#44; localization&#44; histology and lymph node metastases&#46; This means that the majority of patients had a BMI &#60;30&#44; the most common breast cancer was an invasive ductal carcinoma&#44; T1&#44; located in the external breast quadrants and the majority of patients had no axillary metastization&#44; as determined by histology&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">When compared to PL group&#44; the NL group had a higher percentage of patients older than 60 years and the majority of these patients had tumor breast hookwire marking&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The clinical and demographic characteristics of each group of patients are presented in <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">The univariate analysis showed that the only factors with statistical significance associated with NL were age and BMI &#40;<span class="elsevierStyleItalic">p</span>-values of 0&#46;036 and 0&#46;047&#44; respectively&#41;&#46; The hookwire mark seemed to have influence in the NL group &#40;<span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;087&#41;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">These results were further explored with multivariate analysis&#46; The multivariate analysis showed that&#44; controlling for the remaining variables&#44; the <span class="elsevierStyleItalic">odds</span> of having a NL was 2 times higher in women older than 60&#44; compared to the ones younger than 60 years &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;02&#44; 95&#37;CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;96&#8211;4&#46;24&#44; <span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;065&#41;&#44; and 3&#46;8 times higher in obese women &#40;BMI &#8805;30&#41; when compared to non obese &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;8&#44; 95&#37;CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;10&#8211;13&#46;01&#44; <span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;034&#41;&#46; Hookwire mark of the breast tumor seemed to raise the <span class="elsevierStyleItalic">odds</span> of having a NL&#44; nevertheless statistical significance could not be demonstrated when considering a significance value of 0&#46;05 &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;69&#44; 95&#37;CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;82&#8211;3&#46;50&#44; <span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;156&#41;&#46;The remaining factors &#40;size&#44; histology&#44; localization and SLN metastases&#41; did not seem to influence SLN identification&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">The analysis regarding the association between lymph node metastization and NL&#44; did not show significance when controlling for BMI&#44; age and hookwire mark &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;29&#44; 95&#37;CI&#58; 0&#46;55&#8211;3&#46;03&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;565&#41;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">In the matched pairs analysis the percentage of lymph node metastases was 23&#37; in the case group &#40;NL&#41; and 19&#37; in the control group &#40;PL&#41; and the estimated <span class="elsevierStyleItalic">odds ratio</span> was 1&#46;33 &#40;<span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;607&#41;&#46; Similarly to the multivariate analysis&#44; these results also suggest that patients with NL may have an increase in the <span class="elsevierStyleItalic">odds</span> of SLN metastases compared to patients with PL&#44; but no statistical significance was demonstrated&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0230" class="elsevierStylePara elsevierViewall">Since 2001 many factors have been described as being associated with the failure of SLN detection in lymphoscintigraphy &#40;<a class="elsevierStyleCrossRef" href="#tbl2">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl2"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">In spite of each paper describing the main factor that influenced the lymphoscintigraphy result in their study&#44; generally they did not compare two groups of patients with similar characteristics &#40;a control group was not defined&#41; and did not analyze the axillary involvement after controlling the other factors that might influence the sentinel lymph node identification during lymphoscintigraphy&#44; thus the possibility of confounding bias cannot be excluded&#46; There is lack of information about the specific influence of each factor&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Our study selected factors related to patients and to tumor characteristics&#44; which can influence the lymphoscintigraphy result&#46; Besides&#44; we also considered the presence or absence of axillary lymph nodes metastases&#46; We analyzed each factor separately and&#44; finally&#44; controlling the most influencing variables&#44; we studied the probability of axillary metastases&#46; The obtained results were confirmed trough uni- and multivariate analysis and case-control study&#44; which strengths the results&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">From the seven factors studied&#44; only age and BMI were significantly associated with NL in univariate analysis&#46; The hookwire marking of the breast lesion prior to lymphoscintigraphy may have some impact&#44; because of a tendency to increase the <span class="elsevierStyleItalic">odds</span> of having a NL was verified&#44; however without any statistical confirmation&#46; The other factors did not seem to influence the lymphoscintigraphy result&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">In terms of older age influencing the non identification of the SLN&#44; this result is in accordance with other studies<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">9&#44;10&#44;14</span></a> that reported that older woman had an <span class="elsevierStyleItalic">odds ratio</span> of 1&#46;07 of failure to identify the SLN in lymphoscintigraphy&#44; while in our study the <span class="elsevierStyleItalic">odds ratio</span> was about 2&#46; In elder people lymph nodes fat degeneration increases&#44; lymphatic flow slows and radioactive colloid recognition and phagocytosis by macrophages or histiocytes within the lymph node may be reduced&#46; These factors decrease the node&#39;s capacity to retain the radioactive colloid&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Concerning the influence of high BMI in the non visualization of the SLN&#44; our results are similar to those<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">5&#44;12&#44;14&#44;15</span></a> that reported a higher risk of failure to identify the SLN when BMI was higher than 28 &#40;in our study we found an increasing risk when BMI was superior to 30&#41;&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">The association between breast hookwire marking and failure of lymphoscintigraphic mapping existed in our study&#46; The same result&#44; but with statistical significance&#44; was shown by Pritsivelis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> They consider that an interval between breast hookwire marking and lymphoscintigraphy should be respected&#44; to reduce the inflammation&#44; edema and hematoma related to the procedure&#46; Other aspect that can be related is the radiopharmaceutical injection site&#46; Radiopharmaceutical migration might be reduced if the injection is intra or peri-tumoral&#44; which means that it is near the hookwire mark&#46; Therefore&#44; it is important to do lymphoscintigraphy before hookwire marking&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">In spite of tumor size&#44; histology and localization being described in literature as common factors associated with NL&#44; in our study we did not found statistical evidence regarding these factors&#46; This may be due to the fact that the majority of the breast lesions were invasive ductal carcinoma &#40;about 80&#37;&#41;&#44; T1 &#40;about 68&#37;&#41; and were located in the external quadrants &#40;about 60&#37;&#41;&#46; Furthermore&#44; the percentage distribution between the PL and NL groups was very similar&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Despite current theories stating that there is a connection between NL and axillary lymph nodes metastization&#44; in our study&#44; there was no significant difference between PL and NL groups&#44; when controlling for the factors age&#44; BMI and hookwire marking&#46; We believe that this statistical methodology of controlling the most important factors that influence the examination results can avoid biases&#44; and consequently&#44; allows a more accurate analysis&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Some studies suggest that when there is no evidence of SLN&#44; a second radiopharmaceutical injection at a different site<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">16&#44;17</span></a> or a hybrid SPECT&#47;CT study<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">7&#44;18</span></a> should be performed&#46; These procedures increase the SLN identification rate&#46; As previously said&#44; there are aspects related to patients that can influence the SLN in lymphoscintigraphy and&#44; in these specific patients&#44; one should bear in mind complementary procedures &#40;second injection and SPECT&#47;CT&#41; to overcome this limitation&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Even considering the fact of being a retrospective study&#44; our analysis included a large cohort of patients&#44; a rigorous statistical analysis was applied and it was performed in a reference cancer center where protocols are defined and fully adhered to&#46; Some of the published studies had a low SLN detection rate in lymphoscintigraphy &#40;&#60;90&#37;&#41;&#44; but the detection rate in our study was high &#40;98&#37;&#41;&#46; All these aspects increase the confidence in our results&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Although SLN non identification is a rare situation&#44; we stress the clinical impact of our results&#44; mainly because they alert to the existence of factors&#44; other than lymph node metastases&#44; associated with a negative lymphoscintigraphy and influencing this result&#46; Obviously&#44; these factors cannot be assumed as contraindications for the examination&#44; but they should be taken into account when nuclear medicine physician interprets lymphoscintigraphy and alternative strategies should be used when necessary &#40;second injection&#44; SPECT&#47;CT&#44; <span class="elsevierStyleItalic">etc&#46;</span>&#41;&#46; These factors may not only be associated to pathological characteristics of the cancer but&#44; even more important&#44; be related to patient characteristics&#44; which are easily detected&#46; In addition&#44; these results express why it is advisable to perform lymphoscintigraphy before breast hookwire marking&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0290" class="elsevierStylePara elsevierViewall">Our results show that there may be factors directly related to SLN non visualization in lymphoscintigraphy&#44; namely the patient&#39;s age&#44; body mass index and breast cancer hookwire marking prior to lymphoscintigraphy&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">When these factors were controlled&#44; we did not find statistical evidence in the association between negative lymphoscintigraphy and lymph node metastases&#46; Therefore&#44; the empirical association between lymph node identification failure in lymphoscintigraphy and axillary metastization should be considered with caution&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0300" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#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">To evaluate factors associated with non identification of the sentinel lymph node &#40;SLN&#41; in lymphoscintigraphy of breast cancer patients and analyze the relationship with SLN metastases&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A single-center&#44; cross-sectional and retrospective study was performed&#46; Forty patients with lymphoscintigraphy without sentinel lymph node identification &#40;negative lymphoscintigraphy &#8211; NL&#41; were enrolled&#46; The control group included 184 patients with SLN identification &#40;positive lymphoscintigraphy &#8211; PL&#41;&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Evaluated factors were age&#44; body mass index &#40;BMI&#41;&#44; tumor size&#44; histology&#44; localization&#44; preoperative breast lesion hookwire &#40;harpoon&#41; marking and SLN metastases&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The statistical analysis was performed with uni- and multivariate logistic regression models and matched-pairs analysis&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Age &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;036&#41; or having BMI &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;047&#41; were the only factors significantly associated with NL&#46; Being &#8805;60 years with a BMI &#8805;30 increased the <span class="elsevierStyleItalic">odds</span> of having a NL 2 and 3&#46;8 times&#44; respectively&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Marking with hookwire seems to increase the likelihood of NL&#44; but demonstrated statistical significance is lacking &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;087&#41;&#46; The other tested variables did not affect the examination result&#46; When controlling for age&#44; BMI and marking with the harpoon&#44; a significant association between lymph node metastization and NL was not found &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;565&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The most important factors related with non identification of SLN in the patients were age&#44; BMI and marking with hook wire&#46; However&#44; only the first two had statistical importance&#46; When these variables were controlled&#44; no association was found between NL and axillary metastases&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Evaluar los factores relacionados con la no identificaci&#243;n del ganglio centinela &#40;GC&#41; en la linfogammagraf&#237;a de pacientes con c&#225;ncer de mama y su relaci&#243;n con met&#225;stasis en el GC&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y metodos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio unic&#233;ntrico&#44; transversal y retrospectivo&#46; Se seleccionaron 40 pacientes con linfogammagraf&#237;as sin identificaci&#243;n de GC &#40;linfogammagraf&#237;a negativa - LN&#41;&#46; El grupo control incluy&#243; 184 pacientes con identificaci&#243;n del GC &#40;linfogammagraf&#237;a positiva - LP&#41;&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Los factores evaluados fueron&#58; edad&#44; &#237;ndice de masa corporal &#40;IMC&#41;&#44; tama&#241;o&#44; histolog&#237;a&#44; localizaci&#243;n&#44; marcaci&#243;n preoperatoria del tumor con arp&#243;n e met&#225;stasis en el GC&#46; El an&#225;lisis estad&#237;stico se realiz&#243; mediante modelos de regresi&#243;n log&#237;stica univariante y multivariante y an&#225;lisis pareado&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La edad &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;036&#41; y el IMC &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;047&#41; fueron los &#250;nicos factores asociados significativamente con LN&#46; Tener edad &#8805; 60 a&#241;os o IMC &#8805; 30 elevaron la probabilidad de tener una LN 2 y 3&#46;8 veces&#44; respectivamente&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La marcaci&#243;n con arp&#243;n parece aumentar la probabilidad de LN&#44; pero sin significaci&#243;n estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;087&#41;&#46; Las otras variables no influyeron el examen&#46; Al controlar edad&#44; IMC y marcaci&#243;n con arp&#243;n&#44; no se encontr&#243; una asociaci&#243;n significativa entre met&#225;stasis de ganglios linf&#225;ticos y LN &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;565&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Los factores m&#225;s importantes relacionados con la no identificaci&#243;n del GC en las pacientes fueron edad&#44; IMC y marcaci&#243;n con arp&#243;n&#44; pero&#44; s&#243;lo los dos primeros tuvieron relevancia estad&#237;stica&#46; Cuando se control&#243; estas variables&#44; no se encontr&#243; asociaci&#243;n entre LN y met&#225;stasis axilares&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y metodos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "tbl1"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Legend&#58; <span class="elsevierStyleItalic">n</span> &#8211; number of patients&#59; IDC &#8211; invasive ductal carcinoma&#59; DCIS &#8211; intermediate or high grade ductal carcinoma <span class="elsevierStyleItalic">in situ</span>&#59; IC &#8211; invasive carcinoma&#59; SLN &#8211; sentinel lymph node&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Factors&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">Lymphoscintigraphy&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">NL &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>40&#41;&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">&#37;&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">PL &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>184&#41;&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">&#37;&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="left" valign="top">Hookwire&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&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="left" valign="top">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;60 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">32&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;60 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&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="left" valign="top">Body mass index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mean &#40;min&#8211;max&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">25&#46;32 &#40;15&#46;5&#8211;38&#41;</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">21&#46;89 &#40;16&#8211;39&#41;</td></tr><tr title="table-row"><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="left" valign="top">&#60;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">177&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">12&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">4&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="left" valign="top">Tumor size &#40;TNM&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mean &#40;min&#8211;max&#41; cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">1&#46;8 &#40;0&#46;1&#8211;5&#46;5&#41;</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">2&#46;0 &#40;0&#46;4&#8211;10&#41;</td></tr><tr title="table-row"><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="left" valign="top">T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tumor histology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IDC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">145&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DCIS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">10&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">7&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">11&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="left" valign="top">Tumor localization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">External quadrant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">112&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Internal quadrant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&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="left" valign="top">SLN metastases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">22&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">147&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab939009.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Clinical and demographic characteristics of the two groups&#58; negative lymphoscintigraphy &#40;NL&#41; and positive lymphoscintigraphy &#40;PL&#41; patients&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl2"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Legend&#58; Positive lymphoscintigraphy&#58; sentinel lymph node was identified in lymphoscintigraphy&#46; Negative lymphoscintigraphy&#58; sentinel lymph node was not identified in lymphoscintigraphy&#46; &#42;Factors those were statistically significant&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study&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">Number of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Lymphoscintigraphy result</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Lymph node metastases&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">Factors analyzed&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">Factors associated with sentinel lymph node non visualization&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="left" valign="top">Pritsivelis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">203&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">na&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age&#44; body mass index&#44; tumor size&#44; previous breast surgery&#44; time between breast cancer biopsy and radiotracer injection for lymphoscintigraphy</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age &#40;mean 64 years&#41;&#42;Body mass index &#40;mean 28&#41;&#42;Previous breast surgery&#42;Time between breast lesion biopsy and lymphoscintigraphy &#40;mean 17 days&#41;&#42;</td></tr><tr title="table-row"><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><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">na&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="left" valign="top">Yung-Feng Lo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">232&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age&#44; tumor size&#44; biopsy method&#44; tumor location&#44; histologic findings&#44; estrogen receptor&#44; progesterone receptor&#44; Her-2 and pathological staging</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age &#40;&#62;50 years&#41;Size &#40;&#62;2<span class="elsevierStyleHsp" style=""></span>cm&#41;&#42;Lymph node metastases&#42;</td></tr><tr title="table-row"><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><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#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  " align="left" valign="top">Birdwell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><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="char" valign="top">136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age&#44; tumor site&#44; tumor size&#44; histologic findings&#44; injection guidance method&#44; diagnostic biopsy type&#44; interval between biopsy and lymphoscintigraphy</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age &#40;mean 64 years&#41;&#42;Intraoperative method for SLN identification&#42;</td></tr><tr title="table-row"><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><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#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  " align="left" valign="top">Tanis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">501&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age&#44; tumor size&#44; location and grade&#44; tracer dose&#44; lymph node status</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age &#40;mean 60 years&#41;&#42;Tracer dose &#40;&#60;100<span class="elsevierStyleHsp" style=""></span>MBq&#41;&#42;Lymph node metastases&#42;</td></tr><tr title="table-row"><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><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#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  " align="left" valign="top">Brenot-Rossi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">332&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">No&#46; of positive lymph nodes&#44; lymphovascular invasion&#44; age &#40;cut-off 70 years old&#41;&#44; prior excisional biopsy&#44; tumor location&#44; histology and size</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Lymph node metastases &#40;&#62;4 lymph nodes&#41;&#42;Lymphovascular invasion&#42;</td></tr><tr title="table-row"><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><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#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  " align="left" valign="top">Goyal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">823&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">na&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age&#44; body mass index&#44; tumor size&#44; tumor location</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age &#40;mean 61 years&#41;&#42;Body mass index &#40;mean 28&#41;&#42;Tumor size &#40;&#62;20<span class="elsevierStyleHsp" style=""></span>mm&#41;&#42;Tumor location &#40;upper outer quadrant&#41;&#42;</td></tr><tr title="table-row"><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><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">na&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="left" valign="top">Rousseau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">280&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age&#44; type of tumor&#44; location of the primary lesion&#44; number of detected SNs</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age &#40;mean 62 years&#41;&#42;</td></tr><tr title="table-row"><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><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#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  " align="left" valign="top">Soran et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><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="char" valign="top">1500&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age&#44; body mass index&#44; tumor characteristics</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age &#40;&#62;50 years&#41;&#42;Body mass index &#40;&#62;30&#41;&#42;</td></tr><tr title="table-row"><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><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar1075" class="elsevierStyleSimplePara elsevierViewall">Summary of studies that referred factors that might be associated with sentinel lymph node non visualization in lymphoscintigraphy&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:18 [
            0 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current status of sentinel lymph-node biopsy in patients with breast cancer"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G&#46; Cheng"
                            1 => "S&#46; Kurita"
                            2 => "D&#46; Torigian"
                            3 => "A&#46; Alavi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00259-010-1577-z"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Nucl Med Mol Imaging"
                        "fecha" => "2011"
                        "volumen" => "38"
                        "paginaInicial" => "562"
                        "paginaFinal" => "575"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20700739"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The sentinel node procedure in breast cancer&#58; nuclear medicine as the starting point"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46; Hindie"
                            1 => "D&#46; Groheux"
                            2 => "I&#46; Brenot-Rossi"
                            3 => "D&#46; Rubello"
                            4 => "J&#46;L&#46; Moretti"
                            5 => "M&#46; Espie"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2967/jnumed.110.081711"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Nucl Med"
                        "fecha" => "2011"
                        "volumen" => "52"
                        "paginaInicial" => "405"
                        "paginaFinal" => "414"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21321267"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Actualizaci&#243;n del consenso sobre la biopsia selective del ganglio centinela en el c&#225;ncer de mama"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Bernet"
                            1 => "A&#46; Pi&#241;ero"
                            2 => "S&#46; Vidal-Sicart"
                            3 => "R&#46; Cano"
                            4 => "J&#46;M&#46; Cordero"
                            5 => "J&#46; Gim&#233;nez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Senol Patol Mam"
                        "fecha" => "2010"
                        "volumen" => "23"
                        "paginaInicial" => "201"
                        "paginaFinal" => "208"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Factors affecting sentinela lymph node detection failure in breast cancer patients using intradermal injection of the tracer"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Abdollahi"
                            1 => "A&#46; Jangjoo"
                            2 => "V&#46;R&#46; Kakhki"
                            3 => "S&#46; Zakavi"
                            4 => "B&#46; Memard"
                            5 => "M&#46; Forghani"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.remn.2009.10.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Med Nucl"
                        "fecha" => "2010"
                        "volumen" => "29"
                        "paginaInicial" => "73"
                        "paginaFinal" => "77"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19931946"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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