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La densidad de los ganglios linfáticos en la linfadenectomía retroperitoneal como marcador novel para predecir la recurrencia en pacientes con cáncer testicular de células germinales: estudio de casos y controles y experiencia clínica a largo plazo de un hospital de referencia terciario
Lymph node density in retroperitoneal lymph node dissection as a novel marker for predicting recurrence in patients with germ cell testicular cancer: A case-control study and long-term clinical experience of a tertiary referral hospital
S. Sarikayaa, N. Karsiyakalib,
Autor para correspondencia
nkarsiyakali@hotmail.com

Autor para correspondencia.
, E. Kayaa, B. Topuza, T. Ebiloglua, M. Zora
a Department of Urology, Gulhane Research and Training Hospital, Ankara, Turquía
b Department of Urology, Cukurca State Hospital, Hakkari, Turquía
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">El c&#225;ncer testicular &#40;CT&#41; representa aproximadamente el 1&#37; de los casos de c&#225;ncer reci&#233;n diagnosticado en hombres y es la neoplasia maligna s&#243;lida m&#225;s com&#250;n en varones j&#243;venes<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a>&#46; La incidencia de CT a nivel mundial ha aumentado en los &#250;ltimos 20<span class="elsevierStyleHsp" style=""></span>a&#241;os&#59; sin embargo&#44; las tasas de incidencia m&#225;s altas se encuentran en las regiones m&#225;s desarrolladas&#44; particularmente en Europa<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Aproximadamente&#44; el 95&#37; de los casos de CT son c&#225;nceres de c&#233;lulas germinales &#40;CCG&#41;&#46; El 52&#37; de los CCG son seminomas y el 48&#37; son tumores de c&#233;lulas germinales no seminomatosos &#40;TCGNS&#59; carcinoma embrionario&#44; coriocarcinoma&#44; tumor del saco vitelino&#44; teratoma&#41;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a>&#46; La incidencia del seminoma aumenta entre los 30-40 a&#241;os de edad y la incidencia de TCGNS aumenta en pacientes m&#225;s j&#243;venes&#44; de entre 20-30 a&#241;os de edad<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">4-6</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La estadificaci&#243;n del CT se basa en la clasificaci&#243;n TNM &#40;T de tumor&#44; N de n&#243;dulo&#47;ganglio y M de met&#225;stasis&#41; de la Union for International Cancer Control &#40;UICC&#41;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a>&#46; Los pacientes en estadio avanzado de CT se dividen en grupos de pron&#243;stico bueno&#44; intermedio y malo seg&#250;n la clasificaci&#243;n del International Germ Cell Cancer Collaborative Group &#40;IGCCCG&#41;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Aunque el tratamiento del CT var&#237;a seg&#250;n el estadio cl&#237;nico &#40;EC&#41; y el tipo de tumor&#44; el primer paso en el abordaje del tratamiento es casi siempre la orquiectom&#237;a inguinal radical&#46; En presencia de met&#225;stasis potencialmente mortales&#44; es posible que se requiera quimioterapia &#40;QT&#41; previa a la orquiectom&#237;a&#46; El CT de c&#233;lulas germinales &#40;CTCG&#41; tiene en general un buen pron&#243;stico&#44; con una tasa de supervivencia global &#40;SG&#41; de m&#225;s del 90&#37; para todos los estadios cuando es tratado con un enfoque multidisciplinario<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">9&#44;10</span></a>&#46; Seg&#250;n el EC del CTCG&#44; se puede realizar seguimiento o administrar QT adyuvante o radioterapia &#40;RT&#41; tras la orquiectom&#237;a inguinal radical<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a>&#46; La decisi&#243;n de tratamiento adyuvante se basa en el tama&#241;o del tumor &#40;&#62; 4<span class="elsevierStyleHsp" style=""></span>cm&#41; y en el estatus de invasi&#243;n de la red testicular para el seminoma&#44; y en el estatus de invasi&#243;n linfovascular &#40;ILV&#41; y el porcentaje de carcinoma embrionario &#40;&#62; 70&#37;&#41; para el TCGNS<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a>&#46; En las &#250;ltimas d&#233;cadas&#44; se han informado tasas de supervivencia a 5 a&#241;os de aproximadamente el 96&#44;6&#37; para todos los estadios del CT tratados con agentes de QT a base de platino y opciones de tratamiento multimodal<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a>&#46; Una de las principales preocupaciones al elegir el tratamiento del CT es la recurrencia de la enfermedad tras las modalidades de tratamiento primario&#46; Sin embargo&#44; la recurrencia del CT puede ocurrir incluso con el tratamiento adyuvante adecuado y acorde con el EC&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En este contexto&#44; creemos que los ur&#243;logos necesitan nuevos marcadores y datos objetivos para la recurrencia de CT&#46; En el presente estudio&#44; nuestro objetivo fue evaluar la densidad de los ganglios linf&#225;ticos &#40;GL&#41; en la disecci&#243;n de los GL retroperitoneales &#40;DGLRP&#41; para determinar el papel de la masa residual tras la QT como factor predictivo de recurrencia en pacientes con CTCG&#46; Adem&#225;s&#44; nuestro objetivo fue presentar los resultados cl&#237;nicos a largo plazo de los pacientes tratados por CTCG en nuestro hospital terciario de referencia de acuerdo con las directrices vigentes de la Asociaci&#243;n Europea de Urolog&#237;a<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materiales y m&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se analizaron retrospectivamente los datos de 185 pacientes varones que recibieron cirug&#237;a de orquiectom&#237;a inguinal radical entre diciembre del 2004 y febrero del 2017 y diagnosticados con CTCG en el Departamento de Urolog&#237;a del Hospital Gulhane Research and Training&#46; Todas las etapas del estudio se planificaron y realizaron de acuerdo con la Declaraci&#243;n de Helsinki&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los pacientes que fueron diagnosticados de tumores de los cordones sexuales&#47;estroma seg&#250;n la evaluaci&#243;n patol&#243;gica fueron excluidos del estudio&#46; Las caracter&#237;sticas demogr&#225;ficas&#44; los niveles de marcadores tumorales s&#233;ricos &#40;MTS&#41; &#40;en el per&#237;odo preoperatorio&#44; postoperatorio y de recurrencia&#41;&#44; las caracter&#237;sticas preoperatorias del tumor&#44; los resultados de la patolog&#237;a&#44; el EC&#44; el manejo en el postoperatorio y el estatus de enfermedad recurrente se recogieron por separado para cada paciente&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Todos los pacientes se sometieron a una tomograf&#237;a computarizada tor&#225;cica y abdominop&#233;lvica con contraste para la estadificaci&#243;n cl&#237;nica preoperatoria&#46; La densidad de los GL se calcul&#243; mediante la f&#243;rmula &#171;la relaci&#243;n entre el n&#250;mero de GL con dep&#243;sitos metast&#225;sicos y el n&#250;mero total de GL resecados en la DGLRP&#187;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Los pacientes se compararon estad&#237;sticamente en t&#233;rminos de caracter&#237;sticas demogr&#225;ficas&#44; caracter&#237;sticas tumorales preoperatorias&#44; niveles de MTS&#44; resultados de patolog&#237;a y manejo del tratamiento de acuerdo con los subtipos de CTCG &#40;seminoma&#44; TCGNS&#41;&#46; Se realiz&#243; un an&#225;lisis de correlaci&#243;n para determinar los par&#225;metros relacionados con la enfermedad recurrente&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico se realiz&#243; utilizando el software Statistical Package for the Social Sciences &#40;SPSS&#41; versi&#243;n 22&#46;0 &#40;IBM Corp&#46;&#44; Armonk&#44; NY&#44; EE&#46; UU&#46;&#41;&#46; La distribuci&#243;n normal de los datos cuantitativos se analiz&#243; mediante las pruebas de Kolmogorov-Smirnov y Shapiro-Wilk&#46; Los datos descriptivos se expresaron como mediana &#40;m&#237;nimo-m&#225;ximo&#41;&#44; n&#250;mero y frecuencia&#46; Se utiliz&#243; la prueba U de Mann-Whitney para la comparaci&#243;n de los datos cuantitativos de los 2 grupos que no presentaron distribuci&#243;n normal&#46; Se utilizaron las pruebas de la chi al cuadrado de Pearson y la prueba exacta de Fisher para la comparaci&#243;n de los datos cualitativos&#44; y la prueba de Kruskal-Wallis para comparar los datos cuantitativos de los 3 grupos de distribuci&#243;n anormal&#46; Al obtener significaci&#243;n estad&#237;stica en la prueba de Kruskal-Wallis&#44; se utiliz&#243; la prueba de Tamhane en el an&#225;lisis post hoc para encontrar el grupo causante de la diferencia&#46; Se realiz&#243; un an&#225;lisis de correlaci&#243;n de Spearman para identificar los factores asociados con la enfermedad recurrente&#46; Se consider&#243; estad&#237;sticamente significativo un valor de p &#60; 0&#44;05 de 2<span class="elsevierStyleHsp" style=""></span>colas&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">La mediana del per&#237;odo de seguimiento fue de 79 &#40;rango&#58; 31-179&#41; meses&#46; La mediana de edad de los pacientes fue de 23 &#40;rango&#58; 16-71&#41; a&#241;os&#46; Ochenta y tres &#40;44&#44;9&#37;&#41; pacientes ten&#237;an tumor testicular en el lado derecho y 102 &#40;55&#44;1&#37;&#41;&#44; en el lado izquierdo&#46; La mediana del tama&#241;o medio del tumor fue de 4 &#40;rango&#58; 1-18&#41; cm&#46; Cinco &#40;2&#44;7&#37;&#41; pacientes ten&#237;an enfermedad metast&#225;sica en el momento del diagn&#243;stico inicial&#46; Las medianas de los niveles de MTS preoperatorios fueron 3&#44;99 &#40;rango&#58; 0&#44;40-832&#44;00&#41; ng&#47;ml&#44; 1&#44;90 &#40;rango&#58; 0-10089&#44;50&#41; UI&#47;ml&#44; 331 &#40;rango&#58; 14-4933&#41; U&#47;l para alfafetoprote&#237;na &#40;AFP&#41;&#44; gonadotropina cori&#243;nica humana-&#946; &#40;HCG-&#946;&#41; y lactato deshidrogenasa &#40;LDH&#41;&#44; respectivamente&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Se realiz&#243; criopreservaci&#243;n de semen preoperatoria en 175 &#40;94&#44;6&#37;&#41; pacientes menores de 40 a&#241;os&#46; Todos los pacientes fueron tratados mediante orquiectom&#237;a inguinal radical y biopsia testicular contralateral simult&#225;neamente&#46; No hubo evidencia de malignidad en ninguna de estas biopsias testiculares contralaterales&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Seg&#250;n los resultados de la muestra de patolog&#237;a&#44; 62 &#40;33&#44;5&#37;&#41; pacientes ten&#237;an seminoma&#44; 60 &#40;32&#44;4&#37;&#41; ten&#237;an TCGNS y 63 &#40;34&#44;1&#37;&#41; ten&#237;an CTCG de tipo mixto&#46; Con base en el sistema de estadificaci&#243;n de la UICC&#44; los pacientes se clasificaron de la siguiente manera&#58; 70 &#40;37&#44;8&#37;&#41; con EC-1A&#44; 21 &#40;11&#44;4&#37;&#41; con EC-1B&#44; 30 &#40;16&#44;2&#37;&#41; con EC-1S&#44; 26 &#40;14&#44;1&#37;&#41; con EC-2A&#44; 28 &#40;15&#44;1&#37;&#41; con EC-2B&#44; 5 &#40;2&#44;7&#37;&#41; con EC-2C y 5 &#40;2&#44;7&#37;&#41; con EC-3&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se observ&#243; invasi&#243;n de la red testicular en 81 &#40;43&#44;8&#37;&#41; pacientes e ILV en 76 &#40;41&#44;1&#37;&#41; pacientes&#46; La mediana del &#237;ndice de proliferaci&#243;n fue de 50&#37; &#40;rango&#58; 5&#37;-95&#37;&#41; y la mediana del &#237;ndice de carcinoma embrionario fue de 10&#37; &#40;rango&#58; 1&#37;-70&#37;&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Seg&#250;n el EC&#44; 48 &#40;25&#44;9&#37;&#41; pacientes fueron tratados mediante seguimiento&#44; 126 &#40;68&#44;1&#37;&#41; pacientes fueron tratados mediante QT y 11 &#40;5&#44;9&#37;&#41; pacientes fueron tratados mediante RT&#46; Un total de 21 &#40;11&#44;4&#37;&#41; pacientes se sometieron a GDLRP-posquimioterapia &#40;DGLRP-PQT&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>a y b&#41;&#46; Aunque durante mucho tiempo se ha considerado la resecci&#243;n de plantilla completa bilateral como el tratamiento est&#225;ndar&#44; tambi&#233;n realizamos modificaciones en las plantillas derecha e izquierda&#44; as&#237; como procedimientos de preservaci&#243;n nerviosa en pacientes seleccionados&#46; En todos los casos se realiz&#243; cirug&#237;a abierta con abordaje anterior transperitoneal&#46; La mediana de GL extra&#237;dos en la DGLRP-PQT fue 12 &#40;rango&#58; 6-12&#41;&#44; la mediana de GL con dep&#243;sitos metast&#225;sicos fue 2 &#40;rango&#58; 0-6&#41; y el valor mediano del porcentaje de densidad de GL fue del 20&#37; &#40;rango&#58; 0&#37;-60&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Los valores medianos de los niveles de los MTS en el per&#237;odo postoperatorio fueron 3&#44;00 &#40;rango&#58; 0-936&#44;00&#41; ng&#47;ml&#44; 1&#44;90 &#40;rango&#58; 0-1&#46;365&#44;00&#41; UI&#47;ml y 219 &#40;rango&#58; 100-4&#46;770&#41; U&#47;l para AFP&#44; HCG-&#946; y LDH&#44; respectivamente&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Al comparar a los pacientes seg&#250;n el subtipo de CCG&#44; se encontr&#243; que aquellos con TCGNS eran significativamente m&#225;s j&#243;venes que los pacientes con seminoma &#40;22 &#91;rango&#58; 16-54 vs&#46; 26 &#91;rango&#58; 19-71&#93;&#44; p &#61; 0&#44;002&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Los pacientes con TCGNS ten&#237;an un tama&#241;o tumoral mayor estad&#237;sticamente significativo&#44; niveles de AFP preoperatorios y postoperatorios m&#225;s altos y una proporci&#243;n superior de ILV &#40;p &#60; 0&#44;001&#44; para cada uno&#41; que los pacientes con seminoma &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Adem&#225;s&#44; los pacientes con TCGNS ten&#237;an estadios pT y cN significativamente m&#225;s altos que los pacientes con seminoma &#40;p &#60; 0&#44;001 y p &#61; 0&#44;005&#44; respectivamente&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; El manejo postoperatorio y las caracter&#237;sticas de DGLRP-PQT de los pacientes seg&#250;n el subtipo de CCG se resumen en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Cinco &#40;2&#44;7&#37;&#41; pacientes ten&#237;an enfermedad recurrente y la mediana del tiempo hasta la recurrencia fue de 22 &#40;rango&#58; 2-31&#41; meses&#46; Se observ&#243; recurrencia precoz &#40;&#62; 2 a&#241;os&#41; y tard&#237;a &#40;&#62; 2 a&#241;os &#91;en el mes 28 en un paciente y el mes 31 en otro&#93;&#41; en 3 &#40;1&#44;6&#37;&#41; y 2 &#40;1&#44;1&#37;&#41; pacientes&#44; respectivamente&#46; Cuatro &#40;2&#44;2&#37;&#41; pacientes presentaron recurrencia retroperitoneal y hubo un &#40;0&#44;5&#37;&#41; caso con focos metast&#225;sicos en el pulm&#243;n y recurrencia retroperitoneal&#46; Los pacientes con solo recurrencia retroperitoneal fueron tratados con DGLRP secundaria y r&#233;gimen de QT adyuvante con 3 ciclos de bleomicina&#44; etop&#243;sido y cisplatino &#40;BEP&#41;&#46; Los pacientes con recurrencia retroperitoneal y focos metast&#225;sicos del pulm&#243;n fueron tratados con DGLRP secundaria &#43; metastasectom&#237;a y QT adyuvante con 4 ciclos de EP &#40;etop&#243;sido&#44; cisplatino&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">No se observ&#243; diferencia estad&#237;sticamente significativa entre los pacientes en t&#233;rminos de recurrencia seg&#250;n el subtipo de CCG &#40;p &#61; 0&#44;336&#41;&#46; Se observ&#243; enfermedad recurrente en 3 &#40;4&#44;8&#37;&#41; de los pacientes con seminoma y 2 &#40;1&#44;6&#37;&#41; de los pacientes con TCGNS &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Al comparar los pacientes con seminoma con y sin invasi&#243;n de la red testicular en t&#233;rminos de enfermedad recurrente&#44; no hubo diferencias estad&#237;sticamente significativas entre los subgrupos &#40;p &#62; 0&#44;05&#41;&#46; Adem&#225;s&#44; cuando se compar&#243; a los pacientes con seminoma en t&#233;rminos de enfermedad recurrente seg&#250;n el tama&#241;o del tumor &#40;&#60; 4<span class="elsevierStyleHsp" style=""></span>cm vs&#46; &#62; 4<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; tampoco hubo diferencias estad&#237;sticamente significativas entre estos subgrupos &#40;p &#62; 0&#44;05&#41;&#46; No hubo diferencias estad&#237;sticamente significativas entre los pacientes con TCGNS con y sin ILV al comparar los subgrupos en t&#233;rminos de enfermedad recurrente &#40;p &#61; 0&#44;500&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">No se encontr&#243; una correlaci&#243;n significativa entre la recurrencia y la edad&#44; el tama&#241;o del tumor&#44; los niveles preoperatorios de los MTS&#44; la invasi&#243;n de la red testicular&#44; la ILV&#44; la tasa de proliferaci&#243;n&#44; los niveles postoperatorios de MTS y el n&#250;mero total de GL resecados en DGLRP-PQT en el an&#225;lisis de correlaci&#243;n de Spearman &#40;p &#62; 0&#44;05&#44; para cada variable&#41;&#46; En contraste&#44; se encontr&#243; una correlaci&#243;n negativa de leve a moderada&#44; pero significativa&#44; entre la recurrencia y el n&#250;mero de GL con dep&#243;sitos metast&#225;sicos y la densidad del GL <span class="elsevierStyleItalic">&#40;r</span> &#61; &#8211;0&#44;490&#44; p &#61; 0&#44;024 y <span class="elsevierStyleItalic">r</span> &#61; &#8211;0&#44;450&#44; p &#61; 0&#44;041&#44; respectivamente&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">En este estudio&#44; mostramos que existe una correlaci&#243;n negativa entre el n&#250;mero de GL con dep&#243;sitos metast&#225;sicos y la densidad de los GL con la enfermedad recurrente&#46; Adem&#225;s&#44; presentamos los resultados cl&#237;nicos a largo plazo de pacientes que tratados mediante orquiectom&#237;a inguinal radical por CTCG&#46; Cuando se examin&#243; a los pacientes seg&#250;n el subtipo de CCG&#44; observamos que&#44; de acuerdo con la literatura&#44; los pacientes con TCGNS eran m&#225;s j&#243;venes y que los niveles de AFP eran m&#225;s altos&#46; No hubo diferencia entre los grupos en t&#233;rminos de niveles de HCG-&#946;&#46; Se observ&#243; que los niveles de LDH&#44; que es un indicador de carga tumoral&#44; tambi&#233;n fueron m&#225;s altos en los pacientes con TCGNS con mayor tama&#241;o tumoral&#46; La invasi&#243;n de la red testicular y la ILV se observaron con mayor frecuencia en pacientes con TCGNS&#46; Por otro lado&#44; la invasi&#243;n de la red testicular&#44; que es un factor de riesgo de enfermedad recurrente en pacientes con seminoma&#44; y la ILV&#44; que es un factor de riesgo de enfermedad recurrente en pacientes con TCGNS&#44; no fueron estad&#237;sticamente significativas en t&#233;rminos de recurrencia de CTCG&#46; Lo anterior puede deberse al bajo n&#250;mero de pacientes con enfermedad recurrente de seminoma y TCGNS en nuestra cohorte de estudio&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Como resultado importante de nuestro estudio&#44; observamos una correlaci&#243;n negativa entre el n&#250;mero de GL con dep&#243;sitos metast&#225;sicos y la densidad de GL con la enfermedad recurrente&#46; La densidad de los GL se describi&#243; por primera vez para el c&#225;ncer de vejiga &#40;CV&#41; con GL positivos tras cistectom&#237;a radical&#46; En sus estudios retrospectivos&#44; Herr<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> y Stein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> demostraron la densidad de los GL como variable de pron&#243;stico &#250;til y significativa en pacientes con CV y GL positivos<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">12&#44;13</span></a>&#46; Un metaan&#225;lisis reciente confirm&#243; que una mayor densidad de GL se asociaba significativamente con una supervivencia libre de enfermedad &#40;SLE&#41;&#44; una supervivencia espec&#237;fica de la enfermedad &#40;SCE&#41; y una SG bajas en pacientes con CV y GL positivos<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a>&#46; Desafortunadamente&#44; debido al bajo n&#250;mero de pacientes con enfermedad recurrente y datos faltantes de los fallecimientos&#44; no pudimos evaluar la asociaci&#243;n de SLE&#44; SCE y SG con la densidad de los GL&#46; En contraste&#44; Beck et al&#46; informaron que el n&#250;mero de GL positivos o la densidad de GL en la DGLRP primaria no parec&#237;a influir en la recurrencia del TCGNS en estadio patol&#243;gico 1B<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a>&#46; La inconsistencia entre este estudio y los resultados de nuestro an&#225;lisis podr&#237;a atribuirse al hecho de que realizamos DGLRP-PQT a los pacientes con masa residual retroperitoneal&#59; tambi&#233;n realizamos DGLRP-PQT a algunos pacientes con TCG seminomatosos&#46; La diferencia entre los subtipos de TCG y el tama&#241;o peque&#241;o de la muestra de nuestra cohorte de pacientes con DGLRP-PQT parece ser la raz&#243;n de esta diversidad en los resultados&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">La recurrencia es la cuesti&#243;n m&#225;s preocupante en los pacientes con CTCG tras orquiectom&#237;a inguinal radical y terapias adyuvantes&#46; Por esta raz&#243;n&#44; la National Comprehensive Cancer Network &#40;NCCN&#41; recomienda un seguimiento cercano con examen f&#237;sico&#44; medici&#243;n de los niveles de MTS y pruebas funcionales de imagen &#40;tomograf&#237;a computarizada tor&#225;cica y abdominop&#233;lvica con contraste o tomograf&#237;a por emisi&#243;n de positrones-tomograf&#237;a computarizada&#41;&#44; especialmente durante los primeros 5 a&#241;os<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a>&#46; Los factores de riesgo de recurrencia incluyen el tama&#241;o del tumor&#44; la invasi&#243;n de la red testicular y la ILV<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a>&#46; Los factores de riesgo de recurrencia tard&#237;a incluyen la carga tumoral inicial&#44; el fracaso de la DGLRP primaria y el teratoma<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">18&#44;19</span></a>&#46; El retroperitoneo es el sitio m&#225;s com&#250;n de recurrencia &#40;&#8764; 45-70&#37;&#41;&#44; independientemente de la enfermedad primaria<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a>&#46; Aunque la recurrencia se da con frecuencia en los primeros 2 a&#241;os como recurrencia precoz&#44; tambi&#233;n puede verse durante los 2 a&#241;os posteriores como recurrencia tard&#237;a&#46; Por lo tanto&#44; los pacientes con CTCG deben recibir un seguimiento a largo plazo&#46; Kollmannsberger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">21</span></a> informaron tasas de recurrencia temprana de aproximadamente 10-40&#37; en pacientes con GCTC en EC-1 tratados mediante seguimiento&#46; O&#39;Shaughnessy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a> informaron unas tasas de prevalencia de recurrencia tard&#237;a del 1 al 6&#37;&#46; A diferencia de la literatura publicada&#44; se observ&#243; recurrencia precoz en solo 3 &#40;1&#44;6&#37;&#41; de los pacientes de nuestra cohorte de estudio&#46; Sin embargo&#44; y de manera similar a la literatura&#44; se observ&#243; recurrencia tard&#237;a en 2 &#40;1&#44;1&#37;&#41; de los pacientes&#46; En nuestra cohorte de estudio&#44; 44 &#40;62&#44;9&#37;&#41; de los pacientes EC-1A&#44; y solo 4 &#40;19&#37;&#41; de los pacientes EC-1B&#44; fueron tratados mediante seguimiento&#59; los dem&#225;s pacientes &#40;16 &#91;76&#44;2&#37;&#93; recibieron QT y 1 &#91;4&#44;8&#37;&#93; recibi&#243; RT&#41; se sometieron a tratamiento adyuvante&#46; El porcentaje alto de reg&#237;menes de tratamiento adyuvante en nuestra cohorte podr&#237;a ser el motivo por el cual nuestras tasas de recurrencia precoz fuesen m&#225;s bajas&#46; En un estudio que evalu&#243; el carboplatino adyuvante en pacientes con seminoma EC-1&#44; las tasas de supervivencia libre de recurrencia durante 2 y 3 a&#241;os fueron del 97&#44;7 y el 94&#44;8&#37;&#44; respectivamente<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Las recurrencias tras RT se dan casi siempre en los GL pulmonares&#44; mediast&#237;nicos y supraclaviculares&#44; los cuales se encuentran fuera del campo RT<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">23</span></a>&#46; Hallemeier et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> comunicaron tasas de recurrencia del 1 y el 2&#37; tras 10 y 20 a&#241;os&#44; respectivamente&#44; en pacientes con seminoma EC-1 en quienes se administr&#243; RT adyuvante&#44; y todas las recurrencias se dieron fuera del sitio de RT&#46; En nuestro grupo de estudio&#44; se aplic&#243; r&#233;gimen adyuvante de 4 ciclos BEP &#43; DGLRP-PQT a 3 de 5 pacientes que tuvieron recurrencia&#46; Los otros 2 pacientes recibieron solo tratamiento adyuvante con 4 ciclos de BEP&#46; Sin embargo&#44; se observ&#243; recurrencia retroperitoneal en todos estos pacientes y uno de ellos present&#243; met&#225;stasis pulmonar adicional&#46; Por otro lado&#44; observamos recurrencia retroperitoneal en solo 3 de los 21 pacientes que se sometieron a DGLRP-PQT&#46; Se observ&#243; recurrencia tard&#237;a en 2 de estos 3 pacientes&#46; La causa m&#225;s importante de recurrencia tard&#237;a en el retroperitoneo es el manejo inadecuado del retroperitoneo durante el tratamiento primario y la extracci&#243;n inadecuada de los GL durante la DGLRP primaria<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a>&#46; Por tanto&#44; es importante que las cirug&#237;as mayores&#44; como la DGLRP&#44; se lleven a cabo por ur&#243;logos experimentados en centros de referencia&#46; La enfermedad recurrente en retroperitoneo tras DGLRP primaria ha sido informada hasta en un 60&#37;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a>&#46; En nuestro estudio&#44; el hecho de que se administre QT &#40;3 o 4 ciclos BEP&#41; a todos los pacientes antes de la DGLRP puede considerarse como el motivo de la baja tasa de recurrencia en estos pacientes&#46; En un estudio de Sharp et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a>&#44; 18 de 19 pacientes que se sometieron a DGLRP no recibieron QT adyuvante&#44; lo que podr&#237;a ser la raz&#243;n de la alta incidencia de recurrencia&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Entre las caracter&#237;sticas restrictivas de nuestro estudio est&#225;n el no haber calculado la SLE&#44; la SCE y la SG&#44; y la falta de evaluaci&#243;n de las toxicidades a largo plazo tras QT y RT&#46; Adem&#225;s&#44; debido a la naturaleza retrospectiva de nuestro estudio&#44; puede haberse dado un sesgo de selecci&#243;n&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusiones</span><p id="par0130" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; los resultados de nuestro estudio sugieren que existe una correlaci&#243;n negativa pero significativa entre el n&#250;mero de GL con dep&#243;sitos metast&#225;sicos y la densidad de los GL con el desarrollo de la enfermedad recurrente&#46; En centros de referencia de gran volumen&#44; el tratamiento y seguimiento del CTCG y DGLRP-PQT parece ser uno de los criterios m&#225;s importantes para un buen manejo del retroperitoneo&#46; Se necesitan estudios prospectivos y multic&#233;ntricos con un mayor n&#250;mero de pacientes con enfermedad metast&#225;sica para confirmar los resultados de nuestro estudio&#46; Finalmente&#44; los niveles de corte para la intensidad de los GL para la enfermedad recurrente pueden lograrse mediante estudios prospectivos&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicto de intereses</span><p id="par0135" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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              "titulo" => "Introduction and objectives"
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    "fechaRecibido" => "2019-11-27"
    "fechaAceptado" => "2020-03-22"
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          "palabras" => array:6 [
            0 => "Tumores de c&#233;lulas germinales"
            1 => "No seminomatoso"
            2 => "Disecci&#243;n de ganglios linf&#225;ticos retroperitoneales"
            3 => "Resultado"
            4 => "Seminoma"
            5 => "C&#225;ncer testicular"
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          "clase" => "keyword"
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          "palabras" => array:6 [
            0 => "Germ cell tumors"
            1 => "Non-seminomatous"
            2 => "Retroperitoneal lymph node dissection"
            3 => "Outcome"
            4 => "Seminoma"
            5 => "Testicular cancer"
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    "resumen" => array:2 [
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n y objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio retrospectivo fue analizar la densidad de los ganglios linf&#225;ticos &#40;GL&#41; en la disecci&#243;n de los GL retroperitoneales &#40;DGLRP&#41; para evaluar la masa residual tras quimioterapia como factor predictivo de recurrencia en pacientes con c&#225;ncer testicular de c&#233;lulas germinales &#40;CTCG&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materiales y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se revisaron retrospectivamente los datos de 185 pacientes operados por CTCG entre diciembre del 2004 y febrero del 2017&#46; Se calcul&#243; la densidad de los GL&#46; Los pacientes se compararon estad&#237;sticamente en t&#233;rminos de caracter&#237;sticas demogr&#225;ficas&#44; caracter&#237;sticas tumorales&#44; niveles de marcadores tumorales s&#233;ricos&#44; estrategias de tratamiento y resultados patol&#243;gicos seg&#250;n los subtipos de CTCG&#46; Se realiz&#243; un an&#225;lisis de correlaci&#243;n para determinar los par&#225;metros relacionados con la enfermedad recurrente&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La mediana de seguimiento fue de 79 &#40;31-179&#41; meses y la mediana de edad de los pacientes fue de 23 &#40;16-71&#41;&#46; El tama&#241;o medio del tumor fue de 4 &#40;1-18&#41; cm&#46; Cinco &#40;2&#44;7&#37;&#41; pacientes ten&#237;an enfermedad metast&#225;sica en el momento del diagn&#243;stico inicial&#46; Se detect&#243; seminoma&#44; TCG no seminomatoso y CTCG de tipo mixto en 62 &#40;33&#44;5&#37;&#41;&#44; en 60 &#40;32&#44;4&#37;&#41; y en 63 &#40;34&#44;1&#37;&#41; pacientes&#44; respectivamente&#46; Tras la orquiectom&#237;a inguinal&#44; 48 &#40;25&#44;9&#37;&#41; pacientes recibieron seguimiento&#44; 126 &#40;68&#44;1&#37;&#41; pacientes se sometieron a quimioterapia y 11 &#40;5&#44;9&#37;&#41; pacientes recibieron radioterapia&#46; Un total de 21 &#40;11&#44;4&#37;&#41; pacientes se sometieron a DGLRP posquimioterapia&#46; Se observ&#243; recurrencia precoz y tard&#237;a en 3 &#40;1&#44;6&#37;&#41; y 2 &#40;1&#44;1&#37;&#41; pacientes&#44; respectivamente&#46; Se encontr&#243; una correlaci&#243;n negativa leve&#47;moderada&#44; pero significativa&#44; entre la recurrencia y el n&#250;mero de GL con dep&#243;sitos metast&#225;sicos y la densidad de los GL <span class="elsevierStyleItalic">&#40;r</span> &#61; &#8211;0&#44;490&#44; p &#61; 0&#44;024 y <span class="elsevierStyleItalic">r</span> &#61; &#8211;0&#44;450&#44; p &#61; 0&#44;041&#44; respectivamente&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hubo una correlaci&#243;n negativa entre el n&#250;mero de GL con dep&#243;sitos metast&#225;sicos y la densidad de GL con la enfermedad recurrente&#46;</p></span>"
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            "titulo" => "Introducci&#243;n y objetivos"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materiales y m&#233;todos"
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          2 => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction and objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In this retrospective study&#44; we aimed to evaluate lymph node &#40;LN&#41; density in retroperitoneal lymph node dissection &#40;RPLND&#41; to analyze whether residual mass after chemotherapy might behave as predicting factor for recurrence in patients with germ cell testicular cancer &#40;GCTC&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The data of 185 patients that were operated between 12&#47;2004 and 02&#47;2017 because of GCTC were reviewed retrospectively&#46; LN density was calculated&#46; The patients were compared statistically in terms of demographic features&#44; tumor characteristics&#44; serum tumor marker levels&#44; treatment strategies&#44; and pathological results according to GCTC subtypes&#46; Correlation analysis was performed to determine the parameters related to recurrent disease&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The median follow-up was 79 &#40;31-179&#41; months and the median age of the patients was 23 &#40;16-71&#41;&#46; The median tumor size was 4 &#40;1-18&#41; cm&#46; Five &#40;2&#46;7&#37;&#41; patients had metastatic disease at initial diagnosis&#46; Seminoma&#44; non-seminomatous-GCT and mix type-GCTC was detected in 62 &#40;33&#46;5&#37;&#41;&#44; 60 &#40;32&#46;4&#37;&#41; and 63 &#40;34&#46;1&#37;&#41; patients&#44; respectively&#46; Following inguinal orchiectomy&#44; 48 &#40;25&#46;9&#37;&#41; patients underwent follow-up&#44; 126 &#40;68&#46;1&#37;&#41; patients underwent chemotherapy and 11 &#40;5&#46;9&#37;&#41; patients underwent radiotherapy&#46; A total of 21 &#40;11&#46;4&#37;&#41; patients underwent post-chemotherapy RPLND&#46; Early and late recurrence was seen in 3 &#40;1&#46;6&#37;&#41; and 2 &#40;1&#46;1&#37;&#41; of the patients&#44; respectively&#46; A mild to moderate&#44; negative&#44; but significant correlation was found between the recurrence and the number of LNs containing metastatic deposits and LN density &#40;<span class="elsevierStyleItalic">r</span>&#61; &#8211;0&#46;490&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;024 and <span class="elsevierStyleItalic">r</span>&#61; &#8211;0&#46;450&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;041&#44; respectively&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">There was a negative correlation between the number of LNs containing metastatic deposits and LN density and recurrent disease&#46;</p></span>"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">a&#41; Imagen de cirug&#237;a de DGLRP en paciente de 33 a&#241;os con seminoma por masa residual tras quimioterapia&#46; b&#41; Masa retroperitoneal residual resecada en el mismo paciente&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">AFP&#58; alfafetoprote&#237;na&#59; HCG-&#946;&#58; gonadotropina cori&#243;nica humana beta&#44; LDH&#58; lactato deshidrogenasa&#59; TCGNS&#58; tumores de c&#233;lulas germinales no seminomatosos&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mediana &#40;m&#237;n&#46;-m&#225;x&#46;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valor p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;002<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0020">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Derecho&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;378<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Izquierdo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tama&#241;o tumoral &#40;cm&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60; 0&#44;001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0020">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">AFP preoperatoria &#40;ng&#47;ml&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11&#44;40 &#40;0&#44;40-832&#44;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60; 0&#44;001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0020">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">HCG-&#946; preoperatoria &#40;UI&#47;ml&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60; 0&#44;001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0020">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;005<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0020">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n &#40;&#37;&#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">Mediana &#40;m&#237;n&#46;-m&#225;x&#46;&#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">n &#40;&#37;&#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">Mediana &#40;m&#237;n&#46;-m&#225;x&#46;&#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">Valor p&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"><span class="elsevierStyleItalic">Tratamiento postorquiectom&#237;a</span>&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="" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&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"><span class="elsevierStyleHsp" style=""></span>Seguimiento&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;21&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&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">35 &#40;28&#44;5&#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="" valign="\n
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                  \t\t\t\t">&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&#44;001<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0045">&#42;</a>&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"><span class="elsevierStyleHsp" style=""></span>QT&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">38 &#40;61&#44;3&#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="" valign="\n
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                  \t\t\t\t">&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">88 &#40;71&#44;5&#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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&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"><span class="elsevierStyleHsp" style=""></span>RT&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;17&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&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"><span class="elsevierStyleItalic">QT postoperatoria</span>&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="" valign="\n
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                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&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"><span class="elsevierStyleHsp" style=""></span>No&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
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                  \t\t\t\t">23 &#40;37&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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
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                  \t\t\t\t">35 &#40;28&#44;5&#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="" valign="\n
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                  \t\t\t\t">&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&#44;232<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&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"><span class="elsevierStyleHsp" style=""></span>S&#237;&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;62&#44;9&#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="" valign="\n
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                  \t\t\t\t">&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">88 &#40;71&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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"><span class="elsevierStyleItalic">N&#250;mero de ciclos QT</span>&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">3 &#40;1-4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1-4&#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&#44;001<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">c</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0045">&#42;</a>&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"><span class="elsevierStyleItalic">RT postoperatoria</span>&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="" valign="\n
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                  \t\t\t\t">&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"><span class="elsevierStyleHsp" style=""></span>No&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">52 &#40;83&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">123 &#40;100&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&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&#44;001<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0045">&#42;</a>&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"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;16&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30 &#40;30-36&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">DGLRP</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">N&#250;mero total de LN extra&#237;dos en la DGLRP primaria</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;784<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;0-6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \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"><span class="elsevierStyleItalic">Densidad de los ganglios linf&#225;ticos</span><a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">d</span></a><span class="elsevierStyleItalic">&#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;50 &#40;0&#44;17-0&#44;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mediana &#40;m&#237;n&#46;-m&#225;x&#46;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mediana &#40;m&#237;n&#46;-m&#225;x&#46;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tiempo hasta la recurrencia &#40;meses&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Localizaci&#243;n de la recurrencia</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Retroperitoneo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pulm&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">AFP recurrencia &#40;ng&#47;ml&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;076<a class="elsevierStyleCrossRef" href="#tblfn0055"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">HCG-&#946; recurrencia &#40;UI&#47;ml&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;519<a class="elsevierStyleCrossRef" href="#tblfn0055"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">LDH recurrencia &#40;U&#47;l&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">716 &#40;416-1&#46;345&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1507 &#40;726-2&#46;287&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;248<a class="elsevierStyleCrossRef" href="#tblfn0055"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento de la recurrencia</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DGLRP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;100&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;100&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Metastasectom&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Información del artículo
ISSN: 02104806
Idioma original: Español
DOI:10.1016/j.acuro.2020.03.014
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