Validation of sentinel lymph node biopsy in breast cancer women N1–N2 with complete axillary response after neoadjuvant chemotherapy. Multicentre study in Tarragona | Revista Española de Medicina Nuclear e Imagen Molecular (English Edition)

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"apellidos" => "Martin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "j" "identificador" => "aff0050" ] ] ] ] "afiliaciones" => array:10 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Ginecología y Obstetricia, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Oncología, Hospital Universitario de Sant Joan de Reus, Esplugues de Llobregat, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Ginecología y Obstetricia, Hospital Universitario de Sant Joan de Reus, Esplugues de Llobregat, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Cirugía, Hospital Sant Pau y Santa Tecla, Tarragona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Cirugía, Hospital del Vendrell, El Vendrell, Tarragona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Cirugía Plástica, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Unidad Funcional Interdisciplinar Socio Sanitaria cuidados Paliativos, Hospital Universitario de Tarragona Joan XXIII-GIPSS, Tarragona, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Validación de la biopsia selectiva del ganglio centinela en mujeres con cáncer de mama N1-2 con respuesta axilar completa tras la neoadyuvancia. Estudio multicéntrico en la provincia de Tarragona" ] ] "textoCompleto" => "IntroductionThe technique of selective sentinel lymph node biopsy (SLNB) has been proven to be of great benefit to patients affected by breast cancer due to the fact that in patients with a clinically and radiologically negative axilla before surgery and applying the correct technique, could safely avoid a full lymphadenectomy (LDN).<a class="elsevierStyleCrossRefs" href="#bib0105">1–4</a>The low morbidity in patients, the simplicity of the technique and good results have led to an increasing amount of indications for the use of this technique; no longer limited to the original “classic” indications, but we are indicating with certainty SLNB in multi-centric and multifocal tumours, tumours of more than 3cm, in women with previous breast surgery and in women with negative axilla initiating treatment with chemotherapy (CHT).<a class="elsevierStyleCrossRef" href="#bib0125">5</a> Lately steps have been taken to include SLNB in the treatment of women with positive axillary who have undergone neoadjuvant therapy.<a class="elsevierStyleCrossRef" href="#bib0130">6</a>The aim of our study is to evaluate the results of SLNB applied to T1–T2, N1–N2 cases which, post neoadjuvant treatment, presented axillary stage N0.Material and methodA multicentre diagnostic validation study of all patients in the province of Tarragona referred to the Nuclear Medicine department at the University Hospital Joan XXIII of Tarragona.The study, from May 2007 to February 2014, included all patients with breast carcinoma (T1, T2 or T3) with affected axillary lymph nodes (N1 or N2) prior to treatment who, after CHT, showed a complete axillary response (N0).This was a total of 53 patients with invasive carcinoma, all women, who underwent a post-CHT SLNB followed by LDN. The origin of the patients was as follows: 27 patients from the University Hospital Joan XXIII of Tarragona, 14 from the University Hospital Sant Joan de Reus, 7 from Pius Hospital Valls, 4 from the Hospital Sant Pau i Santa Tecla in Tarragona and Hospital del Vendrell and 1 from Verge Hospital de la Cinta Tortosa.We excluded patients with a history of previous axillary surgery, inflammatory carcinoma or contraindication for SLNB. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patient characteristics.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The study was approved by the Research Ethics Committee of the participating centres. All patients were informed and specific informed consent was obtained to participate in the study.Pre-chemotherapy evaluationBreast and axilla areas were assessed by physical examination, mammography, ultrasound and MRI. Morphological imaging aided the placement of a metallic marker to identify the location of the tumour in case of complete response after CHT. In the cases of tumours detectable by ultrasound, this technique was used for placement of the marker; in cases where this was not possible, the stereotaxic guide was employed.In all cases a thick needle tumour biopsy, either ultrasound or stereotactic radio-guided, was carried out for histologic confirmation and determination of prognostic factors was performed; and also histopathologic confirmation of axillary involvement with ultrasound-guided fine needle aspiration biopsy. Chest X-ray, upper body CT scans and bone scintigraphy scans were employed to asses for metastases. This procedure led to initial TNM staging.Neoadjuvant chemotherapyAfter the extension study and radionuclide ventriculography for the assessment of the left ventricle ejection fraction, patients followed a anthracycline and taxane-based treatment:<elsevierMultimedia ident="eq0005"></elsevierMultimedia>A is the adriamycin 60mg/m2; C is cyclophosphamide 600mg/m2 every 21 days for 4 cycles. Taxol: paclitaxel 80mg/m2 every week for 12 weeks.Surgery went ahead as planned 4–6 after finishing this treatment.Patients in whom HER2 was over-expressed were administered trastuzumab (2mg/kg) weekly, starting with taxol treatment with a loading dose of 4mg/kg in the first cycle. After finishing the CHT trastuzumab treatment continued every three weeks for one year.Following surgery, patients overexpressing oestrogen or progesterone receptors were treated with adjuvant tamoxifen or aromatase inhibitor, depending on whether pre- or postmenopausal, for 5 years.Response to chemotherapyAt the end of the last cycle of CHT a breast and axillary MRI was performed in all cases to determine the extent of both tumour response (recorded as full, partial or null) and axillary; in cases of absence of disease, the patient was included in the study. In the last 31 patients, axillary ultrasound reappraisal was also performed. The reason was, that in the first 22 patients who were assessed using only MRI, after an initial assessment of results, excessive incidence of residual axillary involvement was observed and the decision was made to expand the axillary post-CHT study and add sonographic reappraisal.Selective sentinel node biopsy111MBq of 99mTc-nanocolloid albumin (Nanocoll©, GE Healthcare Bio-Sciences) were injected 24h before surgery. The injection was intratumoral in 50 patients: by palpation in 15 patients with detectable residual tumour on physical examination, radioguided with ultrasound in 10 patients in whom there remained a no palpable nodular lesion and radioguided with stereotactic aid in 25 patients in whom the radiological response was complete and was only identifiable by metallic marker. In 3 patients in whom mastectomy was indicated, all with complete radiological response, the tracer was injected via subareolar.Lymphoscintigraphy at 2h was carried out, acquiring planar images of 300s, in anterior and oblique anterior projections, followed by SPECT/CT in cases of extra-axillary drain.If there was no axillary drainage, a subdermal injection of 40MBq 99mTc-nanocolloid was reinjected under the gamma-camera around the area of tumour location, and the new images were acquired 30min p.i. In the operating room lymph nodes with activity were identified with a gamma detection probe Neo2000® (Neoprobe Corporation, Dublin, OH, USA), isolating as sentinels all those with activity superior to 10% of sentinel node (SN) of peak activity. LDN subsequently was performed on all patients and study of the piece to rule out intraoperative detection failures.For their analysis, the SN was fixed in formalin and embedded in paraffin to perform serial sections.The even numbered sections were dyed with haematoxylin–eosin lamellae, and the odd numbered slices with immunohistochemistry for cytokines. In the LDN resection, nodes were isolated, embedded in paraffin and stained with haematoxylin–eosin.Surgical detection, sensitivity, negative predictive value, false negative rate (FNR) and efficiency values were determined.ResultsOf the 53 patients included, after CHT, 40 patients had tumours under 20mm, 9 patients between 21 and 50mm and 4 patients with tumours over 50mm; the latter were cases where in the study previous to CHT the size of the tumours were misestimates.In 6 patients no lymph nodes were observed in lymphoscintigraphy, but in one of these there was surgical detection; in 28% (15/53) a subdermal reinforcement was necessary. Surgical detection rate was 90.5% (48/53), with an average of 2.2 SN per patient, with a range of 0–6.Of the analyzed axillae, in 5 there was no surgical detection and none of these patients had lymph nodes in lymphoscintigraphy. In 4/5 cases (80%) lymph node involvement was observed in the LDN study, in 3 of them, 4 or more nodes (pN2). In one case a complete tumour response without residual involvement in the LDN (pN0) was observed (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The histopathological analysis of the 48 patients in whom the SN was detected surgically, showed complete remission of axillary involvement in 17 cases (35.4%), and 31 showed residual axillary involvement (64.6%). In 28 patients there was residual affectation of SN, in 20% (10/48) of which this was located only in the SN, the remaining LDN being disease free. In 3 patients the SN was negative but there was disease in LDN, resulting in false negatives (FN) (see characteristics in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>With all this we obtained values of sensitivity of 90.3% (28/31), a FNR 9.7% (3/31) and a global test efficiency of 93.7% (45/48).As for the number of lymph nodes and FNR, the results were as follows: in 14 patients only one lymph node was obtained and one of these was FN (7%); 11 patients were extracted in 2 SN, of which one case was FN (9%), and in one patient of the 20 of whom three or more SN were extracted was FN (4.3%).DiscussionWhen we consider the evaluation of a new indication in the technique of SLNB is important to build on the classic parameters of identification rate and FN described and validated in published literature.<a class="elsevierStyleCrossRefs" href="#bib0105">1,2</a> The identification rate of 95% and 5% of FN, generally accepted in the literature, serve as reference<a class="elsevierStyleCrossRefs" href="#bib0135">7,8</a> although some authors do not consider so rigidly values of the classical indications but accepted higher FNR with lower sensitivity rates. Thus, in the meta-analysis of Xing et al.,<a class="elsevierStyleCrossRef" href="#bib0145">9</a> where 21 studies evaluated women with SLNB after CHT, a FNR of 12% was accepted with 88% of identification. In our study, the identification rate is 90.5% and FNR is 9.7%; within the range accepted by the literature.But the controversy is derived from the great methodological variety that is found in various studies, which makes difficult comparison and standardization of the technique that we apply in these cases. Inclusion criteria of patients in the studies are not standardized, which complicates the task of comparing results. Some studies categorize the patients as N1 and N1–2 before the CHT and obtained FNR ranging from 8% to 14.2%.<a class="elsevierStyleCrossRefs" href="#bib0150">10,11</a> In the meta-analysis of Khan et al. FN rates in SLNB post-neoadjuvant therapy range from 0 to 40%; but the inclusion criteria were found to very variable; there were publications that accepted patients with inflammatory carcinoma.<a class="elsevierStyleCrossRef" href="#bib0130">6</a> In the NSABP-27 study N0 and N1 patients were included and FNR in the N1group varied from 8.9 to 12.3% depending on the pathological response after CHT.<a class="elsevierStyleCrossRef" href="#bib0160">12</a>Even more important is how the axilla was evaluated before deciding whether or not to carry out SLNB; since we know that 40% of women with positive axillary after CHT become negative.<a class="elsevierStyleCrossRef" href="#bib0165">13</a> There are published studies involving patients and only a single physical examination<a class="elsevierStyleCrossRef" href="#bib0160">12</a> and others utilizing imaging techniques such as axillary ultrasound, as in the Boughey et al.<a class="elsevierStyleCrossRef" href="#bib0170">14</a> Boughey reported that FN in the group in which no axillary ultrasound is done could reach 12.6%, while in the group that axillary ultrasound is done the FNR fell 9.5%.<a class="elsevierStyleCrossRef" href="#bib0170">14</a> There is therefore a current trend in the evaluation of axillary status being performed using ultrasound technique after the CHT if we are considering performing SLNB.<a class="elsevierStyleCrossRef" href="#bib0175">15</a>Other methodological differences to be seen in the different studies include: the site of injection of the tracer; whether reinjection was necessary or not; the use of dual mapping techniques radiotracer and blue dye; etc. The injection site of the tracer is also related to tumour response to the CHT; in cases where there is no previously placed clip, intra-tumoural injection can be difficult especially if the tumour has a complete radiographic response.Some authors routinely use the periareolar via arguing that the CHT alters the distribution of lymphoid tissue, the breast and areola being rich in nodes, suffers less in this sense;<a class="elsevierStyleCrossRefs" href="#bib0180">16–18</a> however, the reality is that the effects of CHT on intramammary lymphatic system are not well known.The Spanish Society of Senology and Breast Pathology, in its consensus guide on the SLNB indicates the intratumoral route in the “classical” cases of SLNB but concludes that each patient should be individualized and tailored to committee decisions.<a class="elsevierStyleCrossRef" href="#bib0140">8</a>In our study all injections were intratumoral in cases of breast conserving surgery, since all patients had metal clip placed pre CHT, and detection data achieved was within the standards. In the ACOSOG Z1071<a class="elsevierStyleCrossRef" href="#bib0195">19</a> study and NSABP-27<a class="elsevierStyleCrossRef" href="#bib0160">12</a> patients with intratumoral injection, subdermal, periareolar and dingle mapping, either only with blue dye or radiotracer or both (dual mapping) were included. In NSABP B27<a class="elsevierStyleCrossRef" href="#bib0160">12</a> a FNR of 9.3% was detected with dual mapping and the ACOSOG Z1071 study found a FNR of 10.8% with double mapping and FNR of 20.3% in the single mapping (without differentiating between radiotracer or dye).<a class="elsevierStyleCrossRef" href="#bib0195">19</a>In our study we use only radiotracer in all cases and our FNR is 9.7%; similar or better than in many of the studies with dual mapping.Another aspect to consider is whether the number of nodes obtained could influence the resulting FNR. In ACOSOG Z1071 the FN is lower for more than 3 lymph nodes compared with that for 2 lymph nodes.<a class="elsevierStyleCrossRef" href="#bib0195">19</a>In other studies of SLNB before CHT different FN values are reported according to the number of resected lymph nodes: 18% when only one node is removed, 10% for 2 and 7% for 3 nodes.<a class="elsevierStyleCrossRef" href="#bib0200">20</a>In our study, the group where only one node was obtained, FNR was 7%; in the group where 2 SN were extracted FNR was 9% and in the group with 3 or more resected SN, 4.3%, i.e. consistent with the literature. But the most interesting fact was that of 5 patients in which no drain was shown, 4 of them had affected lymph nodes.There may come a time for us to consider also avoiding lymphadenectomy in the group with positive nodes and evaluate only irradiating the axillary zone. We should wait for results of the multicentre studies which are currently in progress.ConclusionWe think it is very interesting to consider the SLNB after CHT in patients who have had a complete axillary response to neoadjuvant treatment, irrespective of the initial state of the axilla for 2 main reasons; one because it gives us reliable information on the state of the axilla after treatment (we evaluate the response of the axilla to the CHT), which can be very useful in terms of prognosis; and secondly, because it has led to changes in our behaviour avoiding surgical LDN in cases with complete axillary pathological response.Conflict of interestThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres824595" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec821074" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres824596" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec821075" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and method" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Pre-chemotherapy evaluation" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Neoadjuvant chemotherapy" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Response to chemotherapy" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Selective sentinel node biopsy" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-09-09" "fechaAceptado" => "2015-12-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec821074" "palabras" => array:6 [ 0 => "Neoadjuvant chemotherapy" 1 => "Breast cancer" 2 => "Axilla" 3 => "Sentinel node" 4 => "False negative rate" 5 => "Lymphadenectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec821075" "palabras" => array:6 [ 0 => "Quimioterapia neoadyuvante" 1 => "Cáncer de mama" 2 => "Axila" 3 => "Ganglio centinela" 4 => "Tasa de falso negativo" 5 => "Linfadenectomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionThe aim of our study was to evaluate sentinel lymph node biopsy (SLNB) as a diagnostic test for assessing the presence of residual metastatic axillary lymph nodes after neoadjuvant chemotherapy, replacing the need for a lymphadenectomy in negative SLNB patients. Material and methodsA multicentre, diagnostic validation study was conducted in the province of Tarragona, on women with T1–T3, N1–N2 breast cancer, who presented with a complete axillary response after neoadjuvant chemotherapy. Study procedures consisted of performing a SLNB followed by lymphadenectomy. ResultsA total of 53 women were included in the study. Surgical detection rate was 90.5% (no sentinel node found in 5 patients). Histopathological analysis of the lymphadenectomy showed complete disease regression of axillary nodes in 35.4% (17/48) of the patients, and residual axillary node involvement in 64.6% (31/48) of them. In lymphadenectomy positive patients, 28 had a positive SLNB (true positive), while 3 had a negative SLNB (false negative). Of the 28 true positive SLNB, the sentinel node was the only positive node in 10 cases. All lymphadenectomy negative cases were SLNB negative. These data yield a sensitivity of 93.5%, a false negative rate of 9.7%, and a global test efficiency of 93.7%. ConclusionsSLNB after chemotherapy in patients with a complete axillary response provides valid and reliable information regarding axillary status after neoadjuvant treatment, and might prevent lymphadenectomy in cases with negative SLNB." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl objetivo de nuestro estudio fue evaluar los resultados de los ganglios obtenidos mediante biopsia selectiva del ganglio centinela (BSGC) en mujeres T1-T3/N1-N2 que después de la neoadyuvancia presentaron una axila N0. Material y métodosSe realizó un estudio multicéntrico de validación diagnóstica en la provincia de Tarragona. Incluimos a mujeres afectadas por cáncer de mama en estadio T1-T3, N1-N2, que presentaron una respuesta axilar completa después de la quimioterapia neoadyuvante. El procedimiento consistió en la realización de la BSGC seguida de la linfadenectomía. El análisis estadístico consistió en la evaluación de la validez de la BSGC mediante la linfadenectomía como gold standard. ResultadosSe incluyeron 53 mujeres. La tasa de detección quirúrgica fue del 90,5% (en 5 pacientes no se encontró el ganglio centinela). El análisis histopatológico de la linfadenectomía mostró remisión completa de los ganglios axilares en el 35,4% (17/48) de las pacientes y enfermedad residual en los ganglios axilares en el 64,6% (31/48) de ellas. En 28 pacientes existía afectación residual en el ganglio centinela, en el 20% (10/48) de las cuales esta se localizaba únicamente en el ganglio centinela, estando el resto de la linfadenectomía libre de enfermedad. En 3 pacientes el ganglio centinela era negativo pero existía enfermedad en la linfadenectomía, resultando falsos negativos. Así, obtenemos una sensibilidad del 93,5%, una tasa de falsos negativos del 9,7% y una eficiencia de prueba global del 93,7%. ConclusionesLa BSGC, después de la quimioterapia en las pacientes que han presentado una respuesta axilar completa, proporciona información válida y fiable sobre el estado axilar después del tratamiento neoadyuvante, y podría evitar la linfadenectomía en casos con ganglio centinela negativo." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Carrera D, de la Flor M, Galera J, Amillano K, Gomez M, Izquierdo V, et al. Validación de la biopsia selectiva del ganglio centinela en mujeres con cáncer de mama N1-2 con respuesta axilar completa tras la neoadyuvancia. Estudio multicéntrico en la provincia de Tarragona. Rev Esp Med Nucl Imagen Mol. 2016;35:221–225." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "DCIS: ductal carcinoma in situ; IDC: infiltrating ductal carcinoma; ILQ: inferior lateral quadrant; IMQ: inferior medial quadrant; JEQ: junction of external quadrants; JIQ: junction of inferior quadrants; JSQ: junction of superior quadrants; LC: lobular carcinoma; LCIS: lobular carcinoma in situ; SLQ: superior lateral quadrant; SMQ: superior medial quadrant." "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53 women \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">x¯ 55 (32–78) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Body mass index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">x¯ 27.5 (22–44) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Breast</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (36%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (64%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Quadrant</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SLQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (47%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ILQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">JEQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (17%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SMQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">JSQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IMQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">JIQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Areola \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Pre chemotherapy size</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><20mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (19%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">20–50mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (60%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">>50mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (21%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Post chemotherapy size</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No residual tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (17%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Microscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (21%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><20mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (38%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">20–50mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (17%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">>50mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Stage</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T1 N1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (19%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2 N1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (56%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T3 N1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (19%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2 N2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T3 N2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Histology of tumour</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IDC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (51%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IDC+DCIS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (37%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IDC+micropapillary C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LC+LCIS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mucinous carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Number of nodes extracted</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (27%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (21%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 or more \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (43%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386310.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "LDN: lymphadenectomy." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tumour post chemotherapy \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">Size mm \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">LDN \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ductal C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4/31 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">lobular C+C in situ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8/9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intraductal C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Microscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1/17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intraductal C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Microscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4/7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386309.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the cases not detected surgically." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ALDN: lymphadenectomy; DCIS: ductal carcinoma in situ; IDC: infiltrating ductal carcinoma; SN: sentinel node." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Histology tumour \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">Size pre-chemotherapy mm \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">Size post-chemotherapy mm \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">Histology SN \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">ALDN histology \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IDC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Microscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5/25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IDC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Microscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2/22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IDC+DCIS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2/24 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386311.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the false negative cases." ] ] 3 => array:5 [ "identificador" => "eq0005" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "AC×4+taxol×12" "Fichero" => "STRIPIN_si2.jpeg" "Tamanyo" => 1199 "Alto" => 13 "Ancho" => 135 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lymphatic mapping and sentinel lymphadenectomy for breast cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.E. 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Original article

Validation of sentinel lymph node biopsy in breast cancer women N1–N2 with complete axillary response after neoadjuvant chemotherapy. Multicentre study in Tarragona

Validación de la biopsia selectiva del ganglio centinela en mujeres con cáncer de mama N1-2 con respuesta axilar completa tras la neoadyuvancia. Estudio multicéntrico en la provincia de Tarragona

D. Carreraa, M. de la Florb,

Corresponding author

miriamjose.delaflor@urv.cat
miriamdelaflor@gmail.com

Corresponding author.

, J. Galerab, K. Amillanoc, M. Gomezb, V. Izquierdoa, E. Aguilard, S. Lópeze, M. Martínezf, S. Martínezg, J.M. Serrah, M. Pérezi, L. Martinj

a Servicio de Medicina Nuclear, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain

b Servicio de Ginecología y Obstetricia, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain

c Servicio de Oncología, Hospital Universitario de Sant Joan de Reus, Esplugues de Llobregat, Barcelona, Spain

d Servicio de Ginecología y Obstetricia, Hospital Universitario de Sant Joan de Reus, Esplugues de Llobregat, Barcelona, Spain

e Servicio de Cirugía, Hospital Sant Pau y Santa Tecla, Tarragona, Spain

f Servicio de Cirugía, Hospital del Vendrell, El Vendrell, Tarragona, Spain

g Servicio de Anatomía Patológica, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain

h Servicio de Cirugía Plástica, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain

i Unidad Funcional Interdisciplinar Socio Sanitaria cuidados Paliativos, Hospital Universitario de Tarragona Joan XXIII-GIPSS, Tarragona, Spain

j Servicio de Radiodiagnóstico, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain

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from May 2007 to February 2014&#44; included all patients with breast carcinoma &#40;T1&#44; T2 or T3&#41; with affected axillary lymph nodes &#40;N1 or N2&#41; prior to treatment who&#44; after CHT&#44; showed a complete axillary response &#40;N0&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This was a total of 53 patients with invasive carcinoma&#44; all women&#44; who underwent a post-CHT SLNB followed by LDN&#46; The origin of the patients was as follows&#58; 27 patients from the University Hospital Joan XXIII of Tarragona&#44; 14 from the University Hospital Sant Joan de Reus&#44; 7 from Pius Hospital Valls&#44; 4 from the Hospital Sant Pau i Santa Tecla in Tarragona and Hospital del Vendrell and 1 from Verge Hospital de la Cinta Tortosa&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We excluded patients with a history of previous axillary surgery&#44; inflammatory carcinoma or contraindication for SLNB&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patient characteristics&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The study was approved by the Research Ethics Committee of the participating centres&#46; 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partial or null&#41; and axillary&#59; in cases of absence of disease&#44; the patient was included in the study&#46; In the last 31 patients&#44; axillary ultrasound reappraisal was also performed&#46; The reason was&#44; that in the first 22 patients who were assessed using only MRI&#44; after an initial assessment of results&#44; excessive incidence of residual axillary involvement was observed and the decision was made to expand the axillary post-CHT study and add sonographic reappraisal&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Selective sentinel node biopsy</span><p id="par0080" class="elsevierStylePara elsevierViewall">111MBq of <span class="elsevierStyleSup">99m</span>Tc-nanocolloid albumin &#40;Nanocoll<span class="elsevierStyleSup">&#169;</span>&#44; GE Healthcare Bio-Sciences&#41; were injected 24<span class="elsevierStyleHsp" style=""></span>h before surgery&#46; The injection was intratumoral in 50 patients&#58; by palpation in 15 patients with detectable residual tumour on physical examination&#44; radioguided with ultrasound in 10 patients in whom there remained a no palpable nodular lesion and radioguided with stereotactic aid in 25 patients in whom the radiological response was complete and was only identifiable by metallic marker&#46; In 3 patients in whom mastectomy was indicated&#44; all with complete radiological response&#44; the tracer was injected via subareolar&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Lymphoscintigraphy at 2<span class="elsevierStyleHsp" style=""></span>h was carried out&#44; acquiring planar images of 300<span class="elsevierStyleHsp" style=""></span>s&#44; in anterior and oblique anterior projections&#44; followed by SPECT&#47;CT in cases of extra-axillary drain&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">If there was no axillary drainage&#44; a subdermal injection of 40MBq <span class="elsevierStyleSup">99m</span>Tc-nanocolloid was reinjected under the gamma-camera around the area of tumour location&#44; and the new images were acquired 30<span class="elsevierStyleHsp" style=""></span>min p&#46;i&#46; In the operating room lymph nodes with activity were identified with a gamma detection probe Neo2000&#174; &#40;Neoprobe Corporation&#44; Dublin&#44; OH&#44; USA&#41;&#44; isolating as sentinels all those with activity superior to 10&#37; of sentinel node &#40;SN&#41; of peak activity&#46; LDN subsequently was performed on all patients and study of the piece to rule out intraoperative detection failures&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">For their analysis&#44; the SN was fixed in formalin and embedded in paraffin to perform serial sections&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The even numbered sections were dyed with haematoxylin&#8211;eosin lamellae&#44; and the odd numbered slices with immunohistochemistry for cytokines&#46; In the LDN resection&#44; nodes were isolated&#44; embedded in paraffin and stained with haematoxylin&#8211;eosin&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Surgical detection&#44; sensitivity&#44; negative predictive value&#44; false negative rate &#40;FNR&#41; and efficiency values were determined&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0110" class="elsevierStylePara elsevierViewall">Of the 53 patients included&#44; after CHT&#44; 40 patients had tumours under 20<span class="elsevierStyleHsp" style=""></span>mm&#44; 9 patients between 21 and 50<span class="elsevierStyleHsp" style=""></span>mm and 4 patients with tumours over 50<span class="elsevierStyleHsp" style=""></span>mm&#59; the latter were cases where in the study previous to CHT the size of the tumours were misestimates&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In 6 patients no lymph nodes were observed in lymphoscintigraphy&#44; but in one of these there was surgical detection&#59; in 28&#37; &#40;15&#47;53&#41; a subdermal reinforcement was necessary&#46; Surgical detection rate was 90&#46;5&#37; &#40;48&#47;53&#41;&#44; with an average of 2&#46;2 SN per patient&#44; with a range of 0&#8211;6&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Of the analyzed axillae&#44; in 5 there was no surgical detection and none of these patients had lymph nodes in lymphoscintigraphy&#46; In 4&#47;5 cases &#40;80&#37;&#41; lymph node involvement was observed in the LDN study&#44; in 3 of them&#44; 4 or more nodes &#40;pN2&#41;&#46; In one case a complete tumour response without residual involvement in the LDN &#40;pN0&#41; was observed &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">The histopathological analysis of the 48 patients in whom the SN was detected surgically&#44; showed complete remission of axillary involvement in 17 cases &#40;35&#46;4&#37;&#41;&#44; and 31 showed residual axillary involvement &#40;64&#46;6&#37;&#41;&#46; In 28 patients there was residual affectation of SN&#44; in 20&#37; &#40;10&#47;48&#41; of which this was located only in the SN&#44; the remaining LDN being disease free&#46; In 3 patients the SN was negative but there was disease in LDN&#44; resulting in false negatives &#40;FN&#41; &#40;see characteristics in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">With all this we obtained values of sensitivity of 90&#46;3&#37; &#40;28&#47;31&#41;&#44; a FNR 9&#46;7&#37; &#40;3&#47;31&#41; and a global test efficiency of 93&#46;7&#37; &#40;45&#47;48&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">As for the number of lymph nodes and FNR&#44; the results were as follows&#58; in 14 patients only one lymph node was obtained and one of these was FN &#40;7&#37;&#41;&#59; 11 patients were extracted in 2 SN&#44; of which one case was FN &#40;9&#37;&#41;&#44; and in one patient of the 20 of whom three or more SN were extracted was FN &#40;4&#46;3&#37;&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">When we consider the evaluation of a new indication in the technique of SLNB is important to build on the classic parameters of identification rate and FN described and validated in published literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;2</span></a> The identification rate of 95&#37; and 5&#37; of FN&#44; generally accepted in the literature&#44; serve as reference<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">7&#44;8</span></a> although some authors do not consider so rigidly values of the classical indications but accepted higher FNR with lower sensitivity rates&#46; Thus&#44; in the meta-analysis of Xing et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> where 21 studies evaluated women with SLNB after CHT&#44; a FNR of 12&#37; was accepted with 88&#37; of identification&#46; In our study&#44; the identification rate is 90&#46;5&#37; and FNR is 9&#46;7&#37;&#59; within the range accepted by the literature&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">But the controversy is derived from the great methodological variety that is found in various studies&#44; which makes difficult comparison and standardization of the technique that we apply in these cases&#46; Inclusion criteria of patients in the studies are not standardized&#44; which complicates the task of comparing results&#46; Some studies categorize the patients as N1 and N1&#8211;2 before the CHT and obtained FNR ranging from 8&#37; to 14&#46;2&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10&#44;11</span></a> In the meta-analysis of Khan et al&#46; FN rates in SLNB post-neoadjuvant therapy range from 0 to 40&#37;&#59; but the inclusion criteria were found to very variable&#59; there were publications that accepted patients with inflammatory carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> In the NSABP-27 study N0 and N1 patients were included and FNR in the N1group varied from 8&#46;9 to 12&#46;3&#37; depending on the pathological response after CHT&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Even more important is how the axilla was evaluated before deciding whether or not to carry out SLNB&#59; since we know that 40&#37; of women with positive axillary after CHT become negative&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> There are published studies involving patients and only a single physical examination<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> and others utilizing imaging techniques such as axillary ultrasound&#44; as in the Boughey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> Boughey reported that FN in the group in which no axillary ultrasound is done could reach 12&#46;6&#37;&#44; while in the group that axillary ultrasound is done the FNR fell 9&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> There is therefore a current trend in the evaluation of axillary status being performed using ultrasound technique after the CHT if we are considering performing SLNB&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Other methodological differences to be seen in the different studies include&#58; the site of injection of the tracer&#59; whether reinjection was necessary or not&#59; the use of dual mapping techniques radiotracer and blue dye&#59; etc&#46; The injection site of the tracer is also related to tumour response to the CHT&#59; in cases where there is no previously placed clip&#44; intra-tumoural injection can be difficult especially if the tumour has a complete radiographic response&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Some authors routinely use the periareolar via arguing that the CHT alters the distribution of lymphoid tissue&#44; the breast and areola being rich in nodes&#44; suffers less in this sense&#59;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">16&#8211;18</span></a> however&#44; the reality is that the effects of CHT on intramammary lymphatic system are not well known&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The Spanish Society of Senology and Breast Pathology&#44; in its consensus guide on the SLNB indicates the intratumoral route in the &#8220;classical&#8221; cases of SLNB but concludes that each patient should be individualized and tailored to committee decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In our study all injections were intratumoral in cases of breast conserving surgery&#44; since all patients had metal clip placed pre CHT&#44; and detection data achieved was within the standards&#46; In the ACOSOG Z1071<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> study and NSABP-27<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> patients with intratumoral injection&#44; subdermal&#44; periareolar and dingle mapping&#44; either only with blue dye or radiotracer or both &#40;dual mapping&#41; were included&#46; In NSABP B27<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> a FNR of 9&#46;3&#37; was detected with dual mapping and the ACOSOG Z1071 study found a FNR of 10&#46;8&#37; with double mapping and FNR of 20&#46;3&#37; in the single mapping &#40;without differentiating between radiotracer or dye&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In our study we use only radiotracer in all cases and our FNR is 9&#46;7&#37;&#59; similar or better than in many of the studies with dual mapping&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Another aspect to consider is whether the number of nodes obtained could influence the resulting FNR&#46; In ACOSOG Z1071 the FN is lower for more than 3 lymph nodes compared with that for 2 lymph nodes&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">In other studies of SLNB before CHT different FN values are reported according to the number of resected lymph nodes&#58; 18&#37; when only one node is removed&#44; 10&#37; for 2 and 7&#37; for 3 nodes&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In our study&#44; the group where only one node was obtained&#44; FNR was 7&#37;&#59; in the group where 2 SN were extracted FNR was 9&#37; and in the group with 3 or more resected SN&#44; 4&#46;3&#37;&#44; i&#46;e&#46; consistent with the literature&#46; But the most interesting fact was that of 5 patients in which no drain was shown&#44; 4 of them had affected lymph nodes&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">There may come a time for us to consider also avoiding lymphadenectomy in the group with positive nodes and evaluate only irradiating the axillary zone&#46; We should wait for results of the multicentre studies which are currently in progress&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusion</span><p id="par0200" class="elsevierStylePara elsevierViewall">We think it is very interesting to consider the SLNB after CHT in patients who have had a complete axillary response to neoadjuvant treatment&#44; irrespective of the initial state of the axilla for 2 main reasons&#59; one because it gives us reliable information on the state of the axilla after treatment &#40;we evaluate the response of the axilla to the CHT&#41;&#44; which can be very useful in terms of prognosis&#59; and secondly&#44; because it has led to changes in our behaviour avoiding surgical LDN in cases with complete axillary pathological response&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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              "titulo" => "Neoadjuvant chemotherapy"
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              "titulo" => "Response to chemotherapy"
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              "titulo" => "Selective sentinel node biopsy"
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    "fechaRecibido" => "2015-09-09"
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            0 => "Neoadjuvant chemotherapy"
            1 => "Breast cancer"
            2 => "Axilla"
            3 => "Sentinel node"
            4 => "False negative rate"
            5 => "Lymphadenectomy"
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            0 => "Quimioterapia neoadyuvante"
            1 => "C&#225;ncer de mama"
            2 => "Axila"
            3 => "Ganglio centinela"
            4 => "Tasa de falso negativo"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of our study was to evaluate sentinel lymph node biopsy &#40;SLNB&#41; as a diagnostic test for assessing the presence of residual metastatic axillary lymph nodes after neoadjuvant chemotherapy&#44; replacing the need for a lymphadenectomy in negative SLNB patients&#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 multicentre&#44; diagnostic validation study was conducted in the province of Tarragona&#44; on women with T1&#8211;T3&#44; N1&#8211;N2 breast cancer&#44; who presented with a complete axillary response after neoadjuvant chemotherapy&#46; Study procedures consisted of performing a SLNB followed by lymphadenectomy&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 53 women were included in the study&#46; Surgical detection rate was 90&#46;5&#37; &#40;no sentinel node found in 5 patients&#41;&#46; Histopathological analysis of the lymphadenectomy showed complete disease regression of axillary nodes in 35&#46;4&#37; &#40;17&#47;48&#41; of the patients&#44; and residual axillary node involvement in 64&#46;6&#37; &#40;31&#47;48&#41; of them&#46; In lymphadenectomy positive patients&#44; 28 had a positive SLNB &#40;true positive&#41;&#44; while 3 had a negative SLNB &#40;false negative&#41;&#46; Of the 28 true positive SLNB&#44; the sentinel node was the only positive node in 10 cases&#46; All lymphadenectomy negative cases were SLNB negative&#46; These data yield a sensitivity of 93&#46;5&#37;&#44; a false negative rate of 9&#46;7&#37;&#44; and a global test efficiency of 93&#46;7&#37;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SLNB after chemotherapy in patients with a complete axillary response provides valid and reliable information regarding axillary status after neoadjuvant treatment&#44; and might prevent lymphadenectomy in cases with negative SLNB&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo de nuestro estudio fue evaluar los resultados de los ganglios obtenidos mediante biopsia selectiva del ganglio centinela &#40;BSGC&#41; en mujeres T1-T3&#47;N1-N2 que despu&#233;s de la neoadyuvancia presentaron una axila N0&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio multic&#233;ntrico de validaci&#243;n diagn&#243;stica en la provincia de Tarragona&#46; Incluimos a mujeres afectadas por c&#225;ncer de mama en estadio T1-T3&#44; N1-N2&#44; que presentaron una respuesta axilar completa despu&#233;s de la quimioterapia neoadyuvante&#46; El procedimiento consisti&#243; en la realizaci&#243;n de la BSGC seguida de la linfadenectom&#237;a&#46; El an&#225;lisis estad&#237;stico consisti&#243; en la evaluaci&#243;n de la validez de la BSGC mediante la linfadenectom&#237;a como gold standard&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 53 mujeres&#46; La tasa de detecci&#243;n quir&#250;rgica fue del 90&#44;5&#37; &#40;en 5 pacientes no se encontr&#243; el ganglio centinela&#41;&#46; El an&#225;lisis histopatol&#243;gico de la linfadenectom&#237;a mostr&#243; remisi&#243;n completa de los ganglios axilares en el 35&#44;4&#37; &#40;17&#47;48&#41; de las pacientes y enfermedad residual en los ganglios axilares en el 64&#44;6&#37; &#40;31&#47;48&#41; de ellas&#46; En 28 pacientes exist&#237;a afectaci&#243;n residual en el ganglio centinela&#44; en el 20&#37; &#40;10&#47;48&#41; de las cuales esta se localizaba &#250;nicamente en el ganglio centinela&#44; estando el resto de la linfadenectom&#237;a libre de enfermedad&#46; En 3 pacientes el ganglio centinela era negativo pero exist&#237;a enfermedad en la linfadenectom&#237;a&#44; resultando falsos negativos&#46; As&#237;&#44; obtenemos una sensibilidad del 93&#44;5&#37;&#44; una tasa de falsos negativos del 9&#44;7&#37; y una eficiencia de prueba global del 93&#44;7&#37;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La BSGC&#44; despu&#233;s de la quimioterapia en las pacientes que han presentado una respuesta axilar completa&#44; proporciona informaci&#243;n v&#225;lida y fiable sobre el estado axilar despu&#233;s del tratamiento neoadyuvante&#44; y podr&#237;a evitar la linfadenectom&#237;a en casos con ganglio centinela negativo&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Carrera D&#44; de la Flor M&#44; Galera J&#44; Amillano K&#44; Gomez M&#44; Izquierdo V&#44; et al&#46; Validaci&#243;n de la biopsia selectiva del ganglio centinela en mujeres con c&#225;ncer de mama N1-2 con respuesta axilar completa tras la neoadyuvancia&#46; Estudio multic&#233;ntrico en la provincia de Tarragona&#46; Rev Esp Med Nucl Imagen Mol&#46; 2016&#59;35&#58;221&#8211;225&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">DCIS&#58; ductal carcinoma in situ&#59; IDC&#58; infiltrating ductal carcinoma&#59; ILQ&#58; inferior lateral quadrant&#59; IMQ&#58; inferior medial quadrant&#59; JEQ&#58; junction of external quadrants&#59; JIQ&#58; junction of inferior quadrants&#59; JSQ&#58; junction of superior quadrants&#59; LC&#58; lobular carcinoma&#59; LCIS&#58; lobular carcinoma in situ&#59; SLQ&#58; superior lateral quadrant&#59; SMQ&#58; superior medial quadrant&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">53 women</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">x&#175; 55 &#40;32&#8211;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Body mass index</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">x&#175; 27&#46;5 &#40;22&#8211;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Breast</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;64&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Quadrant</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SLQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;47&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ILQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>JEQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;17&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SMQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>JSQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IMQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>JIQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Areola&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Pre chemotherapy size</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60;20<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;19&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>20&#8211;50<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;50<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Post chemotherapy size</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No residual tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;17&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Microscopic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60;20<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;38&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>20&#8211;50<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;17&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;50<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Stage</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>T1 N1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;19&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>T2 N1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;56&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>T3 N1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;19&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>T2 N2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>T3 N2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Histology of tumour</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IDC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;51&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IDC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>DCIS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;37&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IDC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>micropapillary C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LCIS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mucinous carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Number of nodes extracted</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;27&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3 or more&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;43&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1386310.png"
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">LDN&#58; lymphadenectomy&#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">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tumour post chemotherapy&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">Size mm&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">LDN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ductal C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" 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">4&#47;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">lobular C<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>C in situ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#47;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intraductal C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microscopic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#47;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#47;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="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
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