Association of PET/CT and VATS findings with histology analysis in the study of pleural effusions | Revista Española de Medicina Nuclear e Imagen Molecular (English Edition)

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Hyperuptake of [18F]F-FDG in lower mid-apical segments and apex of LV which is thickened on CMR (A), with active focus on the anterior wall of the right ventricle, with slight thickening on CMR (B) and hyperuptake of the tracer in the left appendage, without practical translation in CMR (C). Axial PET/MR fusion images and axial CMR black blood sequences. Hyperuptake of [18F]F-FDG in lower mid-apical segments and apex of LV wich is thickened on CMR (A), with active focus on the anterior wall of the right ventricle, with slight thickening on CMR (B) and hyperuptake of the tracer in the left appendage, without practical translation in CMR (C)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.R. Garcia, R. Olivero, M. Panelo, L. Mont, L. Pinilla, M.E. Riera, A. Maceira" "autores" => array:7 [ 0 => array:2 [ "nombre" => "J.R." "apellidos" => "Garcia" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Olivero" ] 2 => array:2 [ "nombre" => "M." 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Montoro, I. Sansano, A. Vázquez, F. Ascanio, C. Alemán" "autores" => array:8 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Simó" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "O." "apellidos" => "Persiva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "J.B." "apellidos" => "Montoro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "I." "apellidos" => "Sansano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "A." 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"apellidos" => "Alemán" "email" => array:1 [ 0 => "mcarmen.aleman@vallhebron.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Departments of Nuclear Imaging, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departments of Radiology, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departments of Thoracic Surgery, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departments of Pharmacy, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Departments of Pathology, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Departments of Internal Medicine, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author:" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Asociación de los hallazgos del PET-TAC y la VATS con la histologia pleural en el estudio de los derrames pleurales" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1227 "Ancho" => 2508 "Tamanyo" => 195235 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Pleural findings on PET/CT: a) White arrow: mediastinal lymph nodes; b) Yellow arrow: nodular pleural thickening suggesting malignant origin c) Blue arrow: linear pleural thickening >5 mm non-suggesting malignant origin; d) Purple arrow: pleural nodule suggesting malignant origin." ] ] ] "textoCompleto" => "IntroductionPleural effusions (PEs) are very often malignant and their diagnosis remains difficult, especially in patients with mesothelioma.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> Pleural fluid cytology establishes the diagnosis of malignancy in 60% of cases, with mesotheliomas being the tumors least frequently diagnosed by this procedure.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Chest computed tomography (CT), an important imaging technique, may miss malignant PEs in up to one third of patients.<a class="elsevierStyleCrossRefs" href="#bib0020">4–6</a> PET/CT has shown that it can establish the suspicion of malignancy in more than 90% of patients,<a class="elsevierStyleCrossRefs" href="#bib0035">7–10</a> although currently there are no studies that demonstrate that identifying patients with a low probability of malignant PE might reduce the number of unnecessary procedures.Pleural biopsy by video-assisted thoracoscopic surgery (VATS) can diagnose malignant PE in up to 90% of case.<a class="elsevierStyleCrossRefs" href="#bib0045">9,11</a> It is considered the best technique for the study of PE when malignancy is suspected, and its results are essential for diagnosis and treatment. However, on occasion diagnosis is very difficult to establish and in some patients the biopsy must be repeated in order to obtain a definitive diagnosis.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Therefore, we would expect patients with a positive PET/CT score to show findings suggestive of malignancy on VATS and the result of the pleural biopsy would therefore be diagnostic of malignancy, but a small percentage of patients will remain undiagnosed. In this study, we set out to identify this group of patients and analyse their characteristics. We aimed to establish the association between findings of PET/CT, VATS and the histology of the first pleural biopsy, and also their relation with the final diagnosis of malignancy or non-malignancy in patients with PE.Patients and methodsPatient selectionProspective study of consecutive patients from October 2013 to September 2023. All adult patients with PE and PET/CT scan, were evaluated in a multidisciplinary pleural disease session at our institution. When there was suspicion of malignancy or symptomatic PE, requiring 2 or more therapeutic thoracentesis, it was decided to perform a VATS with pleural biopsy. All this patients were included in the present study. The hospital’s institutional ethics committee (CEIC, Vall d’Hebron University Hospital, PR(AG)149/2012) approved the study protocol and all participants provided written informed consent.Patients includedAfter inclusion, patients were classified into different groups based on the findings.Malignant PE: Malignant cells on cytological examination of the pleural fluid or biopsy specimens. A diagnosis of probable malignancy was established in patients with a primary tumor when non-malignant cells were detected but other potential causes of PE had been ruled out.Benign PE: Parapneumonic, PE associated with bacterial pneumonia, lung abscess, or bronchiectasis. Empyema: presence of pus within the pleural space. Tuberculous: PE with positive pleural fluid culture, pleural biopsy specimen showing granulomas or adenosine deaminase (ADA) levels>43IU/L with consistent disease. Transudates and exudates were associated with heart failure based on history, physical examination, chest-X-ray and response to diuretics. Miscellaneous: PE due to a miscellaneous disease that followed well established clinical criteria. Idiopathic: undiagnosed effusion after complementary examinations; all patients with diagnosis of idiopathic effusion were prospectively followed up until a specific diagnosis was established, or by means of clinical examination and imaging at 1, 3, 6 and every 6 months for a minimum of one year.<a class="elsevierStyleCrossRefs" href="#bib0010">2,9</a>Patients excludedThose patients, even with a PET/CT study, in whom the diagnosis was established by CT or ultrasound pleural biopsy instead of VATS were excluded.Patients with idiopathic PE who died during the first year or were followed up for less than one year were also excluded.PET/CT scan examinationThe PET/CT examination protocol required a minimum 6 -h fast prior to intravenous administration of 3.7 MBq/kg of the radiopharmaceutical 18FDG, fludeoxiglucosa (222–370 MBq). Glucose levels below 160 mg/dL were confirmed before the administration of the radiopharmaceutical agent.Images were acquired with a Siemens Biograph mCT, which combines a 64-crown helical CT (210 KeV, 120 mAs, care dose) with a dedicated full-ring PET and applies the skull cap to the upper third of both femurs. The data from the CT acquisition were also used to correct the attenuation of the PET image. The images generated were interpreted on a Siemens Healthcare Syngo.via station.PET/CT images were interpreted by a nuclear physician and a thoracic radiologist blinded to the final diagnosis, recording a score based on nodular pleural thickening, pleural nodules with SUV > 7.5, lung mass or extra pleural malignancy (10 points each), mammary lymph node with SUV > 4.5 (5 points) and cardiomegaly (−1 point), which according Previous studies have shown a diagnosis of malignant pleural effusion with sensitivity and specificity around 90% with a cut-off value of > 9 points.Video-assisted thoracoscopic surgeryThe intervention was performed under general anesthetic and contralateral selective intubation to the side to be operated on (except in the most frail patients, in whom deep sedation and local anesthetic were performed). With the patient in lateral decubitus, a thoracoscopy port was made and a 10 mm trocar was inserted. The thoracoscope (usually a 10 mm bayonet thoracoscope, which allows to take biospies under visual control with a single port of entry) was introduced through the trocar. Initially, using a suction catheter, the entire pleural effusion present was drained (after the release of fibrin septa, if present). Subsequently, the entire pleural cavity (both the parietal and the visceral pleura) was inspected. The following parameters were recorded in all procedures: appearance of pleural fluid, drained volume, thickening of the visceral pleura, thickening of the parietal pleura, existence of pleural nodules or masses, septa, plaques, trapped lung, and surgeon’s qualitative diagnosis (benign, malignant or indeterminate). In the presence of nodules or pleural masses, samples were taken with a biopsy forceps. If no such lesions were observed, biopsies from different locations of the parietal pleura were performedPleural histologyAll the histological samples were fixed in10% neutral buffered formalin for 12−48 h at room temperature. After fixation, the specimens were dehydrated in a graded series of ethanol solutions, cleared in xylene and embedded in paraffin wax using an automated tissue processor. Paraffin blocs were prepared by embedding the gently orientated tissue in molten paraffin and allowing it to solidify. 3−4 μm cuts were obtained using a microtome and then stained with hematoxylin and eosin (H&E).H&E was reviewed by a pathologist who issued a diagnosis of benignity, suspicion or malignancy to the biopsy according to WHO criteria. In some cases, immunohistochemical stains were used.In some cases, after a first nondiagnostic biopsy, a second pleural biopsy was performed, which was processed and reviewed the same way.Statistical analysisFor descriptive purposes, data are expressed as frequencies, medians and standard deviations (SD). The paired Student’s t-test was used to compare means (or the Mann–Whitney U test when necessary). The chi-squared test (or Fisher’s exact test when necessary) was used to compare clinical, radiological and analytical data and surgical findings in malignant and benign PE. To evaluate the association between the PET/CT, VATS, histology and confirmed malignancy, a multiple logistic regression was performed.Statistical analysis was conducted using the SPSS version 15 (SPSS Inc., Chicago, Illinois, USA) software package. For single-outcome comparisons, or for logistic regression, the observed effect was considered significant with P values of 0.05 or less.ResultsBaseline dataOne hundred and eighty-six patients with PE were evaluated. Seventy-seven had benign PE: 2 complicated parapneumonic, 3 empyema, 3 tuberculous, 3 associated with heart failure, 34 miscellaneous and 32 undiagnosed, and 109 had malignant diagnosis (107 confirmed and 2 probable): 53 lung cancers, 30 mesotheliomas, 10 breast cancers, 3 hematological malignancies, 3 adenocarcinoma of unknown origin and 10 malignant PE of other origins.Differences between clinical characteristics, chest X-ray findings and pleural analysis in relation to the histological result in the first pleural biopsy (benign or malignant) and the final diagnosis are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Malignancy was diagnosed in the first histology test in 95 patients, with 14 false negatives, since the final diagnosis of malignancy was established in 109. Of the 14 patients with a negative first histologic sample, the final diagnosis of malignancy was established during the same diagnostic process in 9 patients (4 with positive cytology, 2 by the second VATS biopsy with diagnosis of epithelioid mesothelioma, 1 with a second negative biopsy who died and was diagnosed with a sarcomatoid mesothelioma in the necropsy, and 2 patients with probable malignant. Two patients with initially diagnosed with idiopathic pleural effusion and 3 patients diagnosed with benign pleural effusion due to asbestos mesothelioma at follow up (three epithelioid and two sarcomatoid).PET/CT score and VATSIn accordance with previous study,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> results of PET/CT show that a score > 9, based on: presence of nodular pleural thickening <10 mm; pleural nodules with SUV > 7.5; lung mass or extrapleural malignancy with a score of 10 each; mammary lymph node with SUV > 4.5 with a score of 5 and existence of cardiomegaly (which subtracts one point from the score) established the suspicion of malignancy in 89 of 95 patients with a first positive histology for malignancy, and was positive in 17 of 91 patients with a negative first histology (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Some of this findings are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>VATS findings are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>; volume of drained pleural fluid and visualization during the procedure of thickening of parietal pleura, thickening of visceral pleura, presence of nodules or pleural masses and thoracic surgeon's clinical impression showed significant differences. Univariate logistic regression of VATS findings showed that the best parameter for establishing the suspicion of malignancy was the presence of pleural nodules or masses; this was not improved by introduction of any of the other VATS variables entered into the analysis.<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows results according to PET/CT score, visualization of pleural nodules or masses in VATS, and the result of the first pleural biopsy and the final diagnosis of malignancy. Of the 72 patients with a PET/CT score ≤ 9 and no nodules or masses on pleuroscopy, 2 presented first diagnostic histology of mesothelioma, 1 of lung adenocarcinoma, 1 was diagnosed as probable malignant due to lung adenocarcinoma without another cause that might explain the PE, and another with a history of contact with asbestos was diagnosed with a benign PE due to asbestos exposure and presented a mesothelioma during follow-up. Of the 32 patients who presented a PET/CT score > 9 but without nodules or masses in the VATS, 27 presented a final diagnosis of malignancy, of whom 20 were already diagnosed in the first histology; and of the 7 patients initially negative for malignancy, 3 presented lymphoma (two non-Hodgkin and one Hodgkin), 2 were diagnosed with epithelioid mesothelioma in the second biopsy, 1 with lung adenocarcinoma and the last one was diagnosed with mesothelioma in the necropsy. Of the 8 patients with a PET/CT score ≤ 9 and pleural nodules or masses on VATS, 5 had a final diagnosis of malignancy: three of them were diagnosed with malignancy in the first biopsy, and 2 underwent a second biopsy during follow-up that was compatible with mesothelioma. Of the 74 patients with a PET/CT score > 9 and pleural masses or nodules on VATS, a final diagnosis of malignancy was established in 72, 69 of them on the first histology and 3 in a second biopsy, which established the diagnosis of mesothelioma in 2 and lung adenocarcinoma in 1.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Combination of the PET/CT score and the visualization of nodules or pleural masses in the VATS showed sensitivity of 92.80 (87.98–97.60), specificity of 92.00 (85.86–98.14), positive predictive value of 94.50 (90.21–98.78), negative predictive value of 89.61 (82.80–96.43), positive likelihood ratio (LR) of 11.600 (5.375–25.032) and negative LR of 0.078 (0.040−0.153).Relationship between PET/CT, VATS and histology<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the associations between PET/CT score, pleural nodules or masses in VATS and histological result of malignancy in the first pleural biopsy, as well as the explained variation attributed to each of the procedures with respect to the definitive diagnosis of malignancy.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe aim of our study is to establish the association between PET/CT and VATS findings, results of pleural biopsy by VATS and patient’s final diagnosis.PET/CT score previously published<a class="elsevierStyleCrossRef" href="#bib0045">9</a> showed results close to 90% for establishing the diagnostic suspicion of malignancy. Various studies have shown that pleural biopsy obtained by VATS continues to be the most cost-effective test for diagnosing malignant PEs, with a sensitivity greater than 90% although in a small group of patients the initial pleural histology is not diagnostic.<a class="elsevierStyleCrossRefs" href="#bib0010">2,11,12,21</a>After analysing the VATS data in our series, we concluded that visualization of pleural nodules or masses during the procedure is the finding that best establishes the diagnostic suspicion of malignancy; Previous studies described that visualization of pleural nodules or masses during VATS is the finding most strongly associated with the identification of malignancy in the first pleural biopsy.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>In this study we analysed the relationship between the suspicion of malignancy established through PET score, visualization of pleural nodules or masses during VATS, histological result of malignancy in the first pleural biopsy, and definitive diagnosis of malignant PE. After a regression analysis with definitive diagnosis of PE as an independent variable, PET/CT score, the existence of pleural nodules or masses, and result of the first pleural histology showed a strong association (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). PET/CT score and the result of the first pleural biopsy were the variables that explained the greatest percentage of the variation found. There are no previous results that analyse the association between PET and VATS.After VATS and with a first pleural biopsy negative for malignancy, 2 patients presented a malignant effusion that had not been predicted by the results of the PET score or by the visualization of pleural nodules or masses. It should be noted that 1 of these patients had been in high intensity contact with asbestos (with close follow-up due to his well-documented evolution to mesothelioma<a class="elsevierStyleCrossRef" href="#bib0110">22</a>). No pleural hypermetabolic involvement was detected but PE didn’t disappear and mesothelioma was diagnosed at follow-up. The other patient had lung adenocarcinoma and cardiomegaly and therefore had a score of 9, but presented hypermetabolic linear thickening and mammary adenopathies with SUV 3.5; no other possible cause of the PE was found. In the rest of the sample (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), despite a benign histological result in the first pleural biopsy, all the other patients in whom the definitive diagnosis was malignant PE had positive PET/CT score or nodules or pleural masses during VATS, or both. The patients with definitive diagnosis of non-malignancy who presented positive PET/CT score or pleural nodules in the VATS comprised 4 with idiopathic PE with more than one year of follow-up, 2 with tuberculosis, 3 with miscellaneous PE (IgG4 pleurisy, Meigs syndrome and pulmonary atelectasis in context of lung adenocarcinoma) and 1 with recurrent PE and heart failure.Although there are no previous studies that can support this paper, our results show an important association between the PET/CT score and the presence of nodules at VATS with the diagnosis of benign or malignant PE. This should be considered at follow-up in these patients, mainly when discrepancies with histological results are detected.Clearly, more studies are needed both to validate the usefulness of the current score in our setting and to establish the association with the VATS findings. However, our results indicate a high association between the findings analysed, with a high percentage of variation in the definitive diagnosis of PE being explained by PET/CT score and the presence of pleural nodules or masses in the VATS, as obviously with the result of first pleural histology. They also show that in the case of negative pleural histology results, patients who present a PET/CT score > 9 or nodules in the VATS, and in the absence of a diagnosis that allows us to explain the findings, should be re-evaluated and the VATS and pleural biopsy examination repeated. Close clinical and radiological follow-up is also mandatory since it is well known that a percentage of patients with idiopathic PE presented a neoplasm, mainly mesothelioma.<a class="elsevierStyleCrossRefs" href="#bib0020">4,13–20</a>Declarations of interestNone." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres2241926" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1875686" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2241927" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1875685" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Patient selection" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Patients included" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Patients excluded" ] ] ] 1 => array:3 [ "identificador" => "sec0030" "titulo" => "PET/CT scan examination" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Video-assisted thoracoscopic surgery" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Pleural histology" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Statistical analysis" ] ] ] ] ] 6 => array:3 [ "identificador" => "sec0050" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Baseline data" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "PET/CT score and VATS" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Relationship between PET/CT, VATS and histology" ] ] ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Declarations of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-06-04" "fechaAceptado" => "2024-08-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1875686" "palabras" => array:4 [ 0 => "PET/CT" 1 => "VATS" 2 => "Pleural biopsy" 3 => "Malignant pleural effusion" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1875685" "palabras" => array:4 [ 0 => "PET-TAC" 1 => "VATS" 2 => "Biopsia pleural" 3 => "Derrame pleural maligno" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionHistological analysis of the pleura obtained by video-assisted thoracoscopic surgery (VATS) is the best diagnostic technique in the study of neoplastic pleural effusions. This study evaluates the relationship between Positron Emission Tomography (PET)/Computed Tomography (CT) and VATS findings, the result of the first pleural biopsy, and the final diagnosis of malignancy or non-malignancy. MethodsProspective study of consecutive patients with pleural effusions undergoing PET/CT and VATS from October 2013 to December 2023. The following variables were recorded: PET/CT score (nodular pleural thickening, pleural nodules with standardized uptake value (SUV) > 7.5, lung mass or extra pleural malignancy, mammary lymph node with SUV > 4.5 and cardiomegaly); VATS data (drained volume, visceral and parietal pleural thickening, nodules or masses, septa, plaques, fluid appearance, trapped lung, and suspected diagnosis of the procedure), as well as the histological study of the first pleural biopsy (benign or malignant) and the final diagnosis of benign or malignant pleural effusion. A logistic regression study of the variables was performed. Results95.8% of the patients with PET/CT and pleuroscopy not suggestive of malignancy had non-malignant histological findings, while 93.2% of the patients with PET/CT and pleuroscopy suggestive of malignancy had malignant histological findings. PET/CT, pleuroscopy, and the result of the first pleural biopsy showed a significant association with the final diagnosis of pleural effusion. ConclusionsThere is a strong association between PET/CT findings, VATS and pleural histology." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl análisis histológico de la pleura obtenido mediante videotoracoscopia asistida (VATS) es la mejor técnica diagnóstica en el estudio de los derrames pleurales neoplásicos. Este estudio evalúa la relación entre la Tomografía por Emisión de Positrones (PET) - Tomografía Axial Computarizada (TAC) y los hallazgos de VATS, el resultado de la primera biopsia pleural y el diagnóstico final de malignidad o no malignidad. MétodosEstudio prospectivo de pacientes consecutivos con derrame pleural sometidos a PET-TAC y VATS desde octubre de 2013 a diciembre de 2023. Se registraron las siguientes variables: puntuación PET-TAC (engrosamiento pleural nodular, nódulos pleurales con valor de SUV > 7,5, masa pulmonar o neoplasia maligna extrapleural, ganglio linfático mamario con SUV > 4,5 y cardiomegalia); datos de la VATS (volumen drenado, engrosamiento pleural visceral y parietal, nódulos o masas, septos, placas, aspecto líquido, pulmón atrapado y diagnóstico de sospecha del procedimiento), así como el resultado histológico de la primera biopsia pleural (benigna o maligna) y el diagnóstico final de derrame pleural benigno o maligno. Se realizó un estudio de regresión logística de las variables. ResultadosEl 95,8% de los pacientes con PET-TAC y pleuroscopia no sugestiva de malignidad tuvieron hallazgos histológicos no malignos, mientras que el 93,2% de los pacientes con PET-TAC y pleuroscopia sugestiva de malignidad tuvieron una histología neoplásica. La PET-TAC, la pleuroscopia y el resultado de la primera biopsia pleural mostraron una asociación significativa con el diagnóstico final de derrame pleural. ConclusionesExiste una fuerte asociación entre los hallazgos de PET-TAC, VATS e histología pleural." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1227 "Ancho" => 2508 "Tamanyo" => 195235 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Pleural findings on PET/CT: a) White arrow: mediastinal lymph nodes; b) Yellow arrow: nodular pleural thickening suggesting malignant origin c) Blue arrow: linear pleural thickening >5 mm non-suggesting malignant origin; d) Purple arrow: pleural nodule suggesting malignant origin." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1847 "Ancho" => 3341 "Tamanyo" => 293176 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Flow chart of first histology and definitive diagnosis of patients with pleural effusion according to PET/CT score and presence of nodules in VATS." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: PE, pleural effusion; PF, pleural fluid; LDH, lactate dehydrogenase." "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Malignant first histology(n = 95) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Non-malignant first histology (n = 91)</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definitive malignant PE (n = 14) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definitive benign PE(n = 77) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (63.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (78.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 (70.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean age, yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 ± 12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 ± 13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69 ± 15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asbestos exposure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (21.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (28.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (14.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hematic fluid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (62.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (64.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 (31.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (64.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (71.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 (32.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">89 (93.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (92.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (77.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (12.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (14.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (11.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiomegaly \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (11.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (14.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (28.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilateral PE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (2.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (21.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (15.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PE size < 1/3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (11.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (21.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 (33.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PE size 1/3-2/3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 (41.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (42.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 (48.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PE size > 2/3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 (47.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (35.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (20.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">pH PF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.35 ± 0.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.30 ± 0.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.41 ± 0.11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glucose PF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 ± 44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">107 ± 46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">119 ± 59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LDH PF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">778 ± 695 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">919 ± 1273 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">955 ± 2373 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leucocytes PF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2243 ± 1754 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3153 ± 5339 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3194 ± 6715 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hematies PF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.13 ± 0.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.15 ± 0.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.15 ± 0.27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Malignant cytology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 (50.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (20%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3653812.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical, chest X-ray and pleural analysis findings according to first pleural histology." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: PE (pleural effusion);" "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Malignant first histology(n = 95) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Non-malignant first histology (n = 91) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definitive malignant PE(n = 109) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PET/CT</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PET/CT score > 9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">89 (93.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 (18.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99 (93.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PET/CT score value \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 ± 11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 ± 6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 ± 11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VATS</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vólume drained \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2191 ± 2500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">879 ± 943 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2107 ± 2377 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Visceral pleural thickening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 (53.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 (23.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 (53.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parietal pleural thickening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64 (67.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 (44.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.002 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69 (63.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pleural nodules or masses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70 (73.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (11%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 (68.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Septa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (14.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (25.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (17.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pleural Calcifications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (6.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (12.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (7.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trapped lung \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 (33.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (24.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 (33.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical surgeon diagnosis: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">·Benign</li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (2.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 (44%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (4.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010">·Malignant</li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 (77.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (5.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 (70.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015">·indeterminate</li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (20%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 (50.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (24.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3653813.png" ] ] ] ] "descripcion" => array:1 [ "en" => "PET/CT data and VATS findings according to the first histology analysis and the final diagnosis of PE." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "R, Adjusted explained variation (%), (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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PET/CT score \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nodules pleuroscopy \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pleural histology \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Definitive diagnosis of malignancy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.813 66.1% (p < 0.001) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.636 40.4% (p < 0.001) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.859 73.8% (p < 0,001) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3653811.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Explained variation in the final diagnosis of PE according to the PET/CT score, the existence of nodules or pleural masses in the VATS, and the result of the first pleural histology." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Etiología del derrame pleural: análisis de más de 3000 toracocentesis consecutivas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.M. Porcel" 1 => "A. Esquerda" 2 => "M. Vives" 3 => "S. Bielsa" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "ArchBronconeumol" "fecha" => "2014" "volumen" => "50" "numero" => "5" "paginaInicial" => "161" "paginaFinal" => "165" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and outcome of patients with idiopathic pleural effusion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Vázquez" 1 => "M. Simó" 2 => "O. Persiva" 3 => "L. Sánchez" 4 => "I. Sansano" 5 => "C. 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Original Article

Association of PET/CT and VATS findings with histology analysis in the study of pleural effusions

Asociación de los hallazgos del PET-TAC y la VATS con la histologia pleural en el estudio de los derrames pleurales

M. Simóa, O. Persivab, L. Sánchezc, J.B. Montorod, I. Sansanoe, A. Vázquezf, F. Ascanioc, C. Alemánf,

Corresponding author

mcarmen.aleman@vallhebron.cat

Corresponding author:

a Departments of Nuclear Imaging, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain

b Departments of Radiology, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain

c Departments of Thoracic Surgery, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain

d Departments of Pharmacy, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain

e Departments of Pathology, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain

f Departments of Internal Medicine, Grupo de Patología Pleural, Universitat Autònoma de Barcelona, University Hospital Vall d’Hebron, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain

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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pleural findings on PET&#47;CT&#58;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">a&#41; White arrow&#58; mediastinal lymph nodes&#59; b&#41; Yellow arrow&#58; nodular pleural thickening suggesting malignant origin c&#41; Blue arrow&#58; linear pleural thickening &#62;5&#8239;mm non-suggesting malignant origin&#59; d&#41; Purple arrow&#58; pleural nodule suggesting malignant origin&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0020" class="elsevierStylePara elsevierViewall">Pleural effusions &#40;PEs&#41; are very often malignant and their diagnosis remains difficult&#44; especially in patients with mesothelioma&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Pleural fluid cytology establishes the diagnosis of malignancy in 60&#37; of cases&#44; with mesotheliomas being the tumors least frequently diagnosed by this procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Chest computed tomography &#40;CT&#41;&#44; an important imaging technique&#44; may miss malignant PEs in up to one third of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> PET&#47;CT has shown that it can establish the suspicion of malignancy in more than 90&#37; of patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;10</span></a> although currently there are no studies that demonstrate that identifying patients with a low probability of malignant PE might reduce the number of unnecessary procedures&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Pleural biopsy by video-assisted thoracoscopic surgery &#40;VATS&#41; can diagnose malignant PE in up to 90&#37; of case&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;11</span></a> It is considered the best technique for the study of PE when malignancy is suspected&#44; and its results are essential for diagnosis and treatment&#46; However&#44; on occasion diagnosis is very difficult to establish and in some patients the biopsy must be repeated in order to obtain a definitive diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Therefore&#44; we would expect patients with a positive PET&#47;CT score to show findings suggestive of malignancy on VATS and the result of the pleural biopsy would therefore be diagnostic of malignancy&#44; but a small percentage of patients will remain undiagnosed&#46; In this study&#44; we set out to identify this group of patients and analyse their characteristics&#46; We aimed to establish the association between findings of PET&#47;CT&#44; VATS and the histology of the first pleural biopsy&#44; and also their relation with the final diagnosis of malignancy or non-malignancy in patients with PE&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patient selection</span><p id="par0035" class="elsevierStylePara elsevierViewall">Prospective study of consecutive patients from October 2013 to September 2023&#46; All adult patients with PE and PET&#47;CT scan&#44; were evaluated in a multidisciplinary pleural disease session at our institution&#46; When there was suspicion of malignancy or symptomatic PE&#44; requiring 2 or more therapeutic thoracentesis&#44; it was decided to perform a VATS with pleural biopsy&#46; All this patients were included in the present study&#46; The hospital&#8217;s institutional ethics committee &#40;CEIC&#44; Vall d&#8217;Hebron University Hospital&#44; PR&#40;AG&#41;149&#47;2012&#41; approved the study protocol and all participants provided written informed consent&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients included</span><p id="par0040" class="elsevierStylePara elsevierViewall">After inclusion&#44; patients were classified into different groups based on the findings&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Malignant PE&#58; Malignant cells on cytological examination of the pleural fluid or biopsy specimens&#46; A diagnosis of probable malignancy was established in patients with a primary tumor when non-malignant cells were detected but other potential causes of PE had been ruled out&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Benign PE&#58; Parapneumonic&#44; PE associated with bacterial pneumonia&#44; lung abscess&#44; or bronchiectasis&#46; Empyema&#58; presence of pus within the pleural space&#46; Tuberculous&#58; PE with positive pleural fluid culture&#44; pleural biopsy specimen showing granulomas or adenosine deaminase &#40;ADA&#41; levels&#62;43IU&#47;L with consistent disease&#46; Transudates and exudates were associated with heart failure based on history&#44; physical examination&#44; chest-X-ray and response to diuretics&#46; Miscellaneous&#58; PE due to a miscellaneous disease that followed well established clinical criteria&#46; Idiopathic&#58; undiagnosed effusion after complementary examinations&#59; all patients with diagnosis of idiopathic effusion were prospectively followed up until a specific diagnosis was established&#44; or by means of clinical examination and imaging at 1&#44; 3&#44; 6 and every 6 months for a minimum of one year&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Patients excluded</span><p id="par0055" class="elsevierStylePara elsevierViewall">Those patients&#44; even with a PET&#47;CT study&#44; in whom the diagnosis was established by CT or ultrasound pleural biopsy instead of VATS were excluded&#46;Patients with idiopathic PE who died during the first year or were followed up for less than one year were also excluded&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">PET&#47;CT scan examination</span><p id="par0060" class="elsevierStylePara elsevierViewall">The PET&#47;CT examination protocol required a minimum 6&#8239;-h fast prior to intravenous administration of 3&#46;7&#8239;MBq&#47;kg of the radiopharmaceutical <span class="elsevierStyleSup">18</span>FDG&#44; fludeoxiglucosa &#40;222&#8211;370&#8239;MBq&#41;&#46; Glucose levels below 160&#8239;mg&#47;dL were confirmed before the administration of the radiopharmaceutical agent&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Images were acquired with a Siemens Biograph mCT&#44; which combines a 64-crown helical CT &#40;210 KeV&#44; 120 mAs&#44; care dose&#41; with a dedicated full-ring PET and applies the skull cap to the upper third of both femurs&#46; The data from the CT acquisition were also used to correct the attenuation of the PET image&#46; The images generated were interpreted on a Siemens Healthcare Syngo&#46;via station&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">PET&#47;CT images were interpreted by a nuclear physician and a thoracic radiologist blinded to the final diagnosis&#44; recording a score based on nodular pleural thickening&#44; pleural nodules with SUV&#8239;&#62;&#8239;7&#46;5&#44; lung mass or extra pleural malignancy &#40;10 points each&#41;&#44; mammary lymph node with SUV&#8239;&#62;&#8239;4&#46;5 &#40;5 points&#41; and cardiomegaly &#40;&#8722;1 point&#41;&#44; which according Previous studies have shown a diagnosis of malignant pleural effusion with sensitivity and specificity around 90&#37; with a cut-off value of &#62; 9 points&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Video-assisted thoracoscopic surgery</span><p id="par0075" class="elsevierStylePara elsevierViewall">The intervention was performed under general anesthetic and contralateral selective intubation to the side to be operated on &#40;except in the most frail patients&#44; in whom deep sedation and local anesthetic were performed&#41;&#46; With the patient in lateral decubitus&#44; a thoracoscopy port was made and a 10&#8239;mm trocar was inserted&#46; The thoracoscope &#40;usually a 10&#8239;mm bayonet thoracoscope&#44; which allows to take biospies under visual control with a single port of entry&#41; was introduced through the trocar&#46; Initially&#44; using a suction catheter&#44; the entire pleural effusion present was drained &#40;after the release of fibrin septa&#44; if present&#41;&#46; Subsequently&#44; the entire pleural cavity &#40;both the parietal and the visceral pleura&#41; was inspected&#46; The following parameters were recorded in all procedures&#58; appearance of pleural fluid&#44; drained volume&#44; thickening of the visceral pleura&#44; thickening of the parietal pleura&#44; existence of pleural nodules or masses&#44; septa&#44; plaques&#44; trapped lung&#44; and surgeon&#8217;s qualitative diagnosis &#40;benign&#44; malignant or indeterminate&#41;&#46; In the presence of nodules or pleural masses&#44; samples were taken with a biopsy forceps&#46; If no such lesions were observed&#44; biopsies from different locations of the parietal pleura were performed</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Pleural histology</span><p id="par0080" class="elsevierStylePara elsevierViewall">All the histological samples were fixed in10&#37; neutral buffered formalin for 12&#8722;48&#8239;h at room temperature&#46; After fixation&#44; the specimens were dehydrated in a graded series of ethanol solutions&#44; cleared in xylene and embedded in paraffin wax using an automated tissue processor&#46; Paraffin blocs were prepared by embedding the gently orientated tissue in molten paraffin and allowing it to solidify&#46; 3&#8722;4&#8239;&#956;m cuts were obtained using a microtome and then stained with hematoxylin and eosin &#40;H&#38;E&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">H&#38;E was reviewed by a pathologist who issued a diagnosis of benignity&#44; suspicion or malignancy to the biopsy according to WHO criteria&#46; In some cases&#44; immunohistochemical stains were used&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In some cases&#44; after a first nondiagnostic biopsy&#44; a second pleural biopsy was performed&#44; which was processed and reviewed the same way&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical analysis</span><p id="par0095" class="elsevierStylePara elsevierViewall">For descriptive purposes&#44; data are expressed as frequencies&#44; medians and standard deviations &#40;SD&#41;&#46; The paired Student&#8217;s <span class="elsevierStyleItalic">t</span>-test was used to compare means &#40;or the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test when necessary&#41;&#46; The chi-squared test &#40;or Fisher&#8217;s exact test when necessary&#41; was used to compare clinical&#44; radiological and analytical data and surgical findings in malignant and benign PE&#46; To evaluate the association between the PET&#47;CT&#44; VATS&#44; histology and confirmed malignancy&#44; a multiple logistic regression was performed&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Statistical analysis was conducted using the SPSS version 15 &#40;SPSS Inc&#46;&#44; Chicago&#44; Illinois&#44; USA&#41; software package&#46; For single-outcome comparisons&#44; or for logistic regression&#44; the observed effect was considered significant with P values of 0&#46;05 or less&#46;</p></span></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Baseline data</span><p id="par0105" class="elsevierStylePara elsevierViewall">One hundred and eighty-six patients with PE were evaluated&#46; Seventy-seven had benign PE&#58; 2 complicated parapneumonic&#44; 3 empyema&#44; 3 tuberculous&#44; 3 associated with heart failure&#44; 34 miscellaneous and 32 undiagnosed&#44; and 109 had malignant diagnosis &#40;107 confirmed and 2 probable&#41;&#58; 53 lung cancers&#44; 30 mesotheliomas&#44; 10 breast cancers&#44; 3 hematological malignancies&#44; 3 adenocarcinoma of unknown origin and 10 malignant PE of other origins&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Differences between clinical characteristics&#44; chest X-ray findings and pleural analysis in relation to the histological result in the first pleural biopsy &#40;benign or malignant&#41; and the final diagnosis are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Malignancy was diagnosed in the first histology test in 95 patients&#44; with 14 false negatives&#44; since the final diagnosis of malignancy was established in 109&#46; Of the 14 patients with a negative first histologic sample&#44; the final diagnosis of malignancy was established during the same diagnostic process in 9 patients &#40;4 with positive cytology&#44; 2 by the second VATS biopsy with diagnosis of epithelioid mesothelioma&#44; 1 with a second negative biopsy who died and was diagnosed with a sarcomatoid mesothelioma in the necropsy&#44; and 2 patients with probable malignant&#46; Two patients with initially diagnosed with idiopathic pleural effusion and 3 patients diagnosed with benign pleural effusion due to asbestos mesothelioma at follow up &#40;three epithelioid and two sarcomatoid&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">PET&#47;CT score and VATS</span><p id="par0120" class="elsevierStylePara elsevierViewall">In accordance with previous study&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> results of PET&#47;CT show that a score &#62; 9&#44; based on&#58; presence of nodular pleural thickening &#60;10&#8239;mm&#59; pleural nodules with SUV&#8239;&#62;&#8239;7&#46;5&#59; lung mass or extrapleural malignancy with a score of 10 each&#59; mammary lymph node with SUV&#8239;&#62;&#8239;4&#46;5 with a score of 5 and existence of cardiomegaly &#40;which subtracts one point from the score&#41; established the suspicion of malignancy in 89 of 95 patients with a first positive histology for malignancy&#44; and was positive in 17 of 91 patients with a negative first histology &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Some of this findings are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">VATS findings are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#59; volume of drained pleural fluid and visualization during the procedure of thickening of parietal pleura&#44; thickening of visceral pleura&#44; presence of nodules or pleural masses and thoracic surgeon&#39;s clinical impression showed significant differences&#46; Univariate logistic regression of VATS findings showed that the best parameter for establishing the suspicion of malignancy was the presence of pleural nodules or masses&#59; this was not improved by introduction of any of the other VATS variables entered into the analysis&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows results according to PET&#47;CT score&#44; visualization of pleural nodules or masses in VATS&#44; and the result of the first pleural biopsy and the final diagnosis of malignancy&#46; Of the 72 patients with a PET&#47;CT score &#8804; 9 and no nodules or masses on pleuroscopy&#44; 2 presented first diagnostic histology of mesothelioma&#44; 1 of lung adenocarcinoma&#44; 1 was diagnosed as probable malignant due to lung adenocarcinoma without another cause that might explain the PE&#44; and another with a history of contact with asbestos was diagnosed with a benign PE due to asbestos exposure and presented a mesothelioma during follow-up&#46; Of the 32 patients who presented a PET&#47;CT score &#62; 9 but without nodules or masses in the VATS&#44; 27 presented a final diagnosis of malignancy&#44; of whom 20 were already diagnosed in the first histology&#59; and of the 7 patients initially negative for malignancy&#44; 3 presented lymphoma &#40;two non-Hodgkin and one Hodgkin&#41;&#44; 2 were diagnosed with epithelioid mesothelioma in the second biopsy&#44; 1 with lung adenocarcinoma and the last one was diagnosed with mesothelioma in the necropsy&#46; Of the 8 patients with a PET&#47;CT score &#8804; 9 and pleural nodules or masses on VATS&#44; 5 had a final diagnosis of malignancy&#58; three of them were diagnosed with malignancy in the first biopsy&#44; and 2 underwent a second biopsy during follow-up that was compatible with mesothelioma&#46; Of the 74 patients with a PET&#47;CT score &#62; 9 and pleural masses or nodules on VATS&#44; a final diagnosis of malignancy was established in 72&#44; 69 of them on the first histology and 3 in a second biopsy&#44; which established the diagnosis of mesothelioma in 2 and lung adenocarcinoma in 1&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Combination of the PET&#47;CT score and the visualization of nodules or pleural masses in the VATS showed sensitivity of 92&#46;80 &#40;87&#46;98&#8211;97&#46;60&#41;&#44; specificity of 92&#46;00 &#40;85&#46;86&#8211;98&#46;14&#41;&#44; positive predictive value of 94&#46;50 &#40;90&#46;21&#8211;98&#46;78&#41;&#44; negative predictive value of 89&#46;61 &#40;82&#46;80&#8211;96&#46;43&#41;&#44; positive likelihood ratio &#40;LR&#41; of 11&#46;600 &#40;5&#46;375&#8211;25&#46;032&#41; and negative LR of 0&#46;078 &#40;0&#46;040&#8722;0&#46;153&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Relationship between PET&#47;CT&#44; VATS and histology</span><p id="par0140" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the associations between PET&#47;CT score&#44; pleural nodules or masses in VATS and histological result of malignancy in the first pleural biopsy&#44; as well as the explained variation attributed to each of the procedures with respect to the definitive diagnosis of malignancy&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">The aim of our study is to establish the association between PET&#47;CT and VATS findings&#44; results of pleural biopsy by VATS and patient&#8217;s final diagnosis&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">PET&#47;CT score previously published<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> showed results close to 90&#37; for establishing the diagnostic suspicion of malignancy&#46; Various studies have shown that pleural biopsy obtained by VATS continues to be the most cost-effective test for diagnosing malignant PEs&#44; with a sensitivity greater than 90&#37; although in a small group of patients the initial pleural histology is not diagnostic&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;11&#44;12&#44;21</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">After analysing the VATS data in our series&#44; we concluded that visualization of pleural nodules or masses during the procedure is the finding that best establishes the diagnostic suspicion of malignancy&#59; Previous studies described that visualization of pleural nodules or masses during VATS is the finding most strongly associated with the identification of malignancy in the first pleural biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In this study we analysed the relationship between the suspicion of malignancy established through PET score&#44; visualization of pleural nodules or masses during VATS&#44; histological result of malignancy in the first pleural biopsy&#44; and definitive diagnosis of malignant PE&#46; After a regression analysis with definitive diagnosis of PE as an independent variable&#44; PET&#47;CT score&#44; the existence of pleural nodules or masses&#44; and result of the first pleural histology showed a strong association &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; PET&#47;CT score and the result of the first pleural biopsy were the variables that explained the greatest percentage of the variation found&#46; There are no previous results that analyse the association between PET and VATS&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">After VATS and with a first pleural biopsy negative for malignancy&#44; 2 patients presented a malignant effusion that had not been predicted by the results of the PET score or by the visualization of pleural nodules or masses&#46; It should be noted that 1 of these patients had been in high intensity contact with asbestos &#40;with close follow-up due to his well-documented evolution to mesothelioma<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#41;&#46; No pleural hypermetabolic involvement was detected but PE didn&#8217;t disappear and mesothelioma was diagnosed at follow-up&#46; The other patient had lung adenocarcinoma and cardiomegaly and therefore had a score of 9&#44; but presented hypermetabolic linear thickening and mammary adenopathies with SUV 3&#46;5&#59; no other possible cause of the PE was found&#46; In the rest of the sample &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; despite a benign histological result in the first pleural biopsy&#44; all the other patients in whom the definitive diagnosis was malignant PE had positive PET&#47;CT score or nodules or pleural masses during VATS&#44; or both&#46; The patients with definitive diagnosis of non-malignancy who presented positive PET&#47;CT score or pleural nodules in the VATS comprised 4 with idiopathic PE with more than one year of follow-up&#44; 2 with tuberculosis&#44; 3 with miscellaneous PE &#40;IgG4 pleurisy&#44; Meigs syndrome and pulmonary atelectasis in context of lung adenocarcinoma&#41; and 1 with recurrent PE and heart failure&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Although there are no previous studies that can support this paper&#44; our results show an important association between the PET&#47;CT score and the presence of nodules at VATS with the diagnosis of benign or malignant PE&#46; This should be considered at follow-up in these patients&#44; mainly when discrepancies with histological results are detected&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Clearly&#44; more studies are needed both to validate the usefulness of the current score in our setting and to establish the association with the VATS findings&#46; However&#44; our results indicate a high association between the findings analysed&#44; with a high percentage of variation in the definitive diagnosis of PE being explained by PET&#47;CT score and the presence of pleural nodules or masses in the VATS&#44; as obviously with the result of first pleural histology&#46; They also show that in the case of negative pleural histology results&#44; patients who present a PET&#47;CT score &#62; 9 or nodules in the VATS&#44; and in the absence of a diagnosis that allows us to explain the findings&#44; should be re-evaluated and the VATS and pleural biopsy examination repeated&#46; Close clinical and radiological follow-up is also mandatory since it is well known that a percentage of patients with idiopathic PE presented a neoplasm&#44; mainly mesothelioma&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;13&#8211;20</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Declarations of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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              "titulo" => "PET&#47;CT score and VATS"
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              "titulo" => "Relationship between PET&#47;CT&#44; VATS and histology"
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            0 => "PET&#47;CT"
            1 => "VATS"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Histological analysis of the pleura obtained by video-assisted thoracoscopic surgery &#40;VATS&#41; is the best diagnostic technique in the study of neoplastic pleural effusions&#46; This study evaluates the relationship between Positron Emission Tomography &#40;PET&#41;&#47;Computed Tomography &#40;CT&#41; and VATS findings&#44; the result of the first pleural biopsy&#44; and the final diagnosis of malignancy or non-malignancy&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Prospective study of consecutive patients with pleural effusions undergoing PET&#47;CT and VATS from October 2013 to December 2023&#46; The following variables were recorded&#58; PET&#47;CT score &#40;nodular pleural thickening&#44; pleural nodules with standardized uptake value &#40;SUV&#41; &#62; 7&#46;5&#44; lung mass or extra pleural malignancy&#44; mammary lymph node with SUV&#8239;&#62;&#8239;4&#46;5 and cardiomegaly&#41;&#59; VATS data &#40;drained volume&#44; visceral and parietal pleural thickening&#44; nodules or masses&#44; septa&#44; plaques&#44; fluid appearance&#44; trapped lung&#44; and suspected diagnosis of the procedure&#41;&#44; as well as the histological study of the first pleural biopsy &#40;benign or malignant&#41; and the final diagnosis of benign or malignant pleural effusion&#46; A logistic regression study of the variables was performed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">95&#46;8&#37; of the patients with PET&#47;CT and pleuroscopy not suggestive of malignancy had non-malignant histological findings&#44; while 93&#46;2&#37; of the patients with PET&#47;CT and pleuroscopy suggestive of malignancy had malignant histological findings&#46; PET&#47;CT&#44; pleuroscopy&#44; and the result of the first pleural biopsy showed a significant association with the final diagnosis of pleural effusion&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">There is a strong association between PET&#47;CT findings&#44; VATS and pleural histology&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">El an&#225;lisis histol&#243;gico de la pleura obtenido mediante videotoracoscopia asistida &#40;VATS&#41; es la mejor t&#233;cnica diagn&#243;stica en el estudio de los derrames pleurales neopl&#225;sicos&#46; Este estudio eval&#250;a la relaci&#243;n entre la Tomograf&#237;a por Emisi&#243;n de Positrones &#40;PET&#41; - Tomograf&#237;a Axial Computarizada &#40;TAC&#41; y los hallazgos de VATS&#44; el resultado de la primera biopsia pleural y el diagn&#243;stico final de malignidad o no malignidad&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo de pacientes consecutivos con derrame pleural sometidos a PET-TAC y VATS desde octubre de 2013 a diciembre de 2023&#46; Se registraron las siguientes variables&#58; puntuaci&#243;n PET-TAC &#40;engrosamiento pleural nodular&#44; n&#243;dulos pleurales con valor de SUV&#8239;&#62;&#8239;7&#44;5&#44; masa pulmonar o neoplasia maligna extrapleural&#44; ganglio linf&#225;tico mamario con SUV&#8239;&#62;&#8239;4&#44;5 y cardiomegalia&#41;&#59; datos de la VATS &#40;volumen drenado&#44; engrosamiento pleural visceral y parietal&#44; n&#243;dulos o masas&#44; septos&#44; placas&#44; aspecto l&#237;quido&#44; pulm&#243;n atrapado y diagn&#243;stico de sospecha del procedimiento&#41;&#44; as&#237; como el resultado histol&#243;gico de la primera biopsia pleural &#40;benigna o maligna&#41; y el diagn&#243;stico final de derrame pleural benigno o maligno&#46; Se realiz&#243; un estudio de regresi&#243;n log&#237;stica de las variables&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">El 95&#44;8&#37; de los pacientes con PET-TAC y pleuroscopia no sugestiva de malignidad tuvieron hallazgos histol&#243;gicos no malignos&#44; mientras que el 93&#44;2&#37; de los pacientes con PET-TAC y pleuroscopia sugestiva de malignidad tuvieron una histolog&#237;a neopl&#225;sica&#46; La PET-TAC&#44; la pleuroscopia y el resultado de la primera biopsia pleural mostraron una asociaci&#243;n significativa con el diagn&#243;stico final de derrame pleural&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Existe una fuerte asociaci&#243;n entre los hallazgos de PET-TAC&#44; VATS e histolog&#237;a pleural&#46;</p></span>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; PE&#44; pleural effusion&#59; PF&#44; pleural fluid&#59; LDH&#44; lactate dehydrogenase&#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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Malignant first histology&#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Non-malignant first histology &#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;91&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definitive malignant PE &#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definitive benign PE&#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;63&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;78&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54 &#40;70&#46;1&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean age&#44; yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#8239;&#177;&#8239;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#8239;&#177;&#8239;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#8239;&#177;&#8239;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asbestos exposure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;21&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;28&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;14&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hematic fluid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;62&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;64&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;31&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;64&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;71&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;32&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dyspnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89 &#40;93&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;92&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;77&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;12&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;14&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;11&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiomegaly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;11&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;14&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;28&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bilateral PE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;2&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;21&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;15&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PE size&#8239;&#60;&#8239;1&#47;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;11&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;21&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;33&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PE size 1&#47;3-2&#47;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;41&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;42&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;48&#46;1&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PE size&#8239;&#62;&#8239;2&#47;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;47&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;35&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;20&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">pH PF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;35&#8239;&#177;&#8239;0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;30&#8239;&#177;&#8239;0&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;41&#8239;&#177;&#8239;0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glucose PF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#8239;&#177;&#8239;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">107&#8239;&#177;&#8239;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">119&#8239;&#177;&#8239;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LDH PF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">778&#8239;&#177;&#8239;695&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">919&#8239;&#177;&#8239;1273&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">955&#8239;&#177;&#8239;2373&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leucocytes PF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2243&#8239;&#177;&#8239;1754&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3153&#8239;&#177;&#8239;5339&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3194&#8239;&#177;&#8239;6715&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hematies PF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;13&#8239;&#177;&#8239;0&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;15&#8239;&#177;&#8239;0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;15&#8239;&#177;&#8239;0&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Malignant cytology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48 &#40;50&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;20&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3653812.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Clinical&#44; chest X-ray and pleural analysis findings according to first pleural histology&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; PE &#40;pleural effusion&#41;&#59;</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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Malignant first histology&#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Non-malignant first histology &#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definitive malignant PE&#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;109&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PET&#47;CT</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PET&#47;CT score &#62; 9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89 &#40;93&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;18&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99 &#40;93&#46;4&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PET&#47;CT score value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#8239;&#177;&#8239;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#8239;&#177;&#8239;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#8239;&#177;&#8239;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VATS</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">V&#243;lume drained&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2191&#8239;&#177;&#8239;2500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">879&#8239;&#177;&#8239;943&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2107&#8239;&#177;&#8239;2377&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Visceral pleural thickening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51 &#40;53&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;23&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58 &#40;53&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parietal pleural thickening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64 &#40;67&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;44&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69 &#40;63&#46;3&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pleural nodules or masses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70 &#40;73&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;11&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75 &#40;68&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Septa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;14&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;25&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;17&#46;4&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pleural Calcifications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;6&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;12&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;7&#46;3&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Trapped lung&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;33&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;24&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Clinical surgeon diagnosis&#58;&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Etiolog&#237;a del derrame pleural&#58; an&#225;lisis de m&#225;s de 3000 toracocentesis consecutivas"
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                        0 => array:2 [
                          "etal" => false
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Article information

ISSN: 22538089
Original language: English

DOI:10.1016/j.remnie.2024.500059

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