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Se han descrito factores de riesgo espec&#237;ficos&#44; ya que el MLA guarda una menor relaci&#243;n con los fototipos claros o la preexistencia de nevus melanoc&#237;ticos y tiende a presentarse en zonas con poca exposici&#243;n a la radiaci&#243;n ultravioleta &#40;RUV&#41;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#8211;7</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Se ha planteado que el trauma cr&#243;nico en &#225;reas acrales puede predisponer a que se presente este tipo de tumor<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a>&#46; Esto se ha sugerido por su presentaci&#243;n m&#225;s frecuente en las zonas de mayor estr&#233;s mec&#225;nico&#44; las &#225;reas delanteras y traseras del pie&#44; sugiriendo que esto ser&#237;a debido a que la presi&#243;n ocasionar&#237;a un mayor da&#241;o de la piel y a su vez a una mayor propensi&#243;n a desarrollar MLA&#44; en comparaci&#243;n con las dem&#225;s zonas consideradas como de no apoyo<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; A pesar de haber menos estudios de MLA en las manos&#44; tambi&#233;n se han observado hallazgos que apoyan esta hip&#243;tesis al encontrar que los melanomas&#44; contrario a lo que ocurre con los nevus&#44; no se localizan en el &#225;rea proximal de la palma sino en los pulpejos y en la zona distal de la palma&#44; donde se suele presentar un mayor estr&#233;s mec&#225;nico<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo del presente estudio fue relacionar la presencia del MLA y sus caracter&#237;sticas con las zonas acrales que se consideran de presi&#243;n y de no presi&#243;n&#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 realiz&#243; un estudio observacional retrospectivo siguiendo las recomendaciones de la gu&#237;a Strobe<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a>&#46; Se recogieron los datos de pacientes con un diagn&#243;stico de MLA que fueron evaluados en la Fundaci&#243;n Cl&#237;nica Vida en Medell&#237;n&#44; Colombia&#44; centro de referencia de la ciudad para el tratamiento del c&#225;ncer de piel&#44; en el per&#237;odo comprendido entre enero del a&#241;o 2016 y agosto de 2020&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los datos se obtuvieron de una fuente de informaci&#243;n mixta por medio de las historias cl&#237;nicas electr&#243;nicas de los pacientes y se realiz&#243; un cuestionario por medio telef&#243;nico para completar la informaci&#243;n faltante&#46; La localizaci&#243;n de la lesi&#243;n fue especificada a trav&#233;s de una imagen enviada al paciente&#44; donde se observaba la extremidad afectada dividida por zonas para que este se&#241;alara el &#225;rea afectada&#44; lo cual permiti&#243; una clasificaci&#243;n objetiva&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Los criterios de inclusi&#243;n fueron los pacientes con diagn&#243;stico de MLA confirmado por histopatolog&#237;a&#44; sin met&#225;stasis a distancia&#44; los cuales fueron excluidos ya que el evento se present&#243; en cuatro casos de los cuales no se contaba con la informaci&#243;n completa del estadio histol&#243;gico del melanoma primario&#46; Se excluyeron los pacientes que hab&#237;an fallecido en el momento del estudio y con quienes no fue posible comunicarse para realizar la encuesta por v&#237;a telef&#243;nica&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">El estudio y todos sus procedimientos fueron aprobados por el Comit&#233; de &#201;tica de la Fundaci&#243;n Cl&#237;nica Vida&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se recogieron variables demogr&#225;ficas como edad y sexo&#46; Se interrog&#243; si exist&#237;a el antecedente de traumatismo directo en la zona del tumor y la dominancia lateral &#40;diestro&#44; zurdo&#41;&#46; Adem&#225;s&#44; al momento de hacer la encuesta telef&#243;nica se registr&#243; el peso y la talla para calcular el &#237;ndice de masa corporal &#40;IMC&#41;&#44; el cual se categoriz&#243; seg&#250;n la clasificaci&#243;n de sobrepeso y obesidad propuesta por el comit&#233; de expertos de la Organizaci&#243;n Mundial de la Salud &#40;OMS&#41;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">La variable dependiente fue la localizaci&#243;n seg&#250;n si estaba sometida a fuerzas de presi&#243;n o no &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; En la cara volar de la mano&#44; se consideraron como zonas de presi&#243;n los dedos y la cabeza de los metacarpianos&#44; ya que son las que sufren m&#225;s estr&#233;s mec&#225;nico con los agarres y donde se suelen presentar m&#225;s lesiones como callos y ampollas<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">8&#44;11&#44;12</span></a>&#46; Por consenso de expertos&#44; el resto de la palma se clasific&#243; como zona de no presi&#243;n&#46; Las u&#241;as se analizaron por separado&#46; En la superficie plantar&#44; de acuerdo con el grado de estr&#233;s mec&#225;nico&#44; se clasific&#243; como zona de presi&#243;n a la cara plantar de los dedos&#44; el antepi&#233;&#44; el mediopi&#233; lateral y el tal&#243;n&#46; El arco plantar se defini&#243; como zona de no presi&#243;n&#46; Las u&#241;as se analizaron por separado&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Se consideraron las siguientes variables independientes&#46; En cuanto a las caracter&#237;sticas tumorales se evalu&#243; su localizaci&#243;n&#44; lateralidad &#40;derecho&#59; izquierdo&#41;&#44; datos histopatol&#243;gicos que incluyeron la profundidad del tumor &#40;Breslow&#58; recogido como variable cualitativa ordinal con intervalos de espesor de T0-T4&#41; y la presencia de ulceraci&#243;n&#46; Tambi&#233;n se evalu&#243; el compromiso metast&#225;sico ganglionar y se clasific&#243; el tumor seg&#250;n el sistema de estadiaje propuesto por el <span class="elsevierStyleItalic">American Joint Committee on Cancer</span> &#40;AJCC&#41; en la octava edici&#243;n<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Las variables categ&#243;ricas se describieron utilizando una distribuci&#243;n de frecuencia absoluta y relativa&#44; las variables cuantitativas utilizando medidas de tendencia central y dispersi&#243;n&#46; La asociaci&#243;n entre variables cualitativas independientes y la variable dependiente se evalu&#243; mediante la prueba de &#967;<span class="elsevierStyleSup">2</span> o prueba exacta de Fisher&#44; cuando la frecuencia esperada fue menor del 5&#37;&#46; Los an&#225;lisis estad&#237;sticos se realizaron con el programa estad&#237;stico SPSS versi&#243;n 21 &#40;IBM Corp&#46;&#44; Armonk&#44; NY&#44; EE&#46; UU&#46;&#41;&#46; La significaci&#243;n estad&#237;stica se estableci&#243; para un valor de p inferior al 5&#37;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0065" class="elsevierStylePara elsevierViewall">Se incluyeron un total de 95 pacientes con MLA &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#44; mediana de edad &#40;rango intercuart&#237;lico &#91;RIQ&#93;&#41; de 59 a&#241;os &#40;50-70&#41;&#44; de los cuales&#44; 59 &#40;62&#44;1&#37;&#41; fueron de sexo femenino&#46; Se report&#243; trauma directo previo en la zona de presentaci&#243;n del melanoma en 18 &#40;18&#44;9&#37;&#41; de los casos &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">De las lesiones evaluadas&#44; 16 &#40;16&#44;8&#37;&#41; se presentaron en las manos y 79 &#40;83&#44;1&#37;&#41; en los pies&#46; Aunque en las manos hubo un leve predominio por el lado derecho &#40;56&#44;2 derecho vs&#46; 43&#44;7&#37; izquierdo&#41;&#44; en los pies hubo m&#225;s melanomas acrales en el lado izquierdo &#40;53&#44;1 izquierdo vs&#46; 46&#44;8&#37; derecho&#41;&#46; La mayor&#237;a de las lesiones fueron <span class="elsevierStyleItalic">in situ</span> &#40;37 &#91;38&#44;9&#37;&#93;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">De los 16 melanomas evaluados en la mano&#44; la mitad se localizaron en las u&#241;as&#44; 6 &#40;37&#44;5&#37;&#41; en la zona de presi&#243;n y 2 &#40;12&#44;5&#37;&#41; en la zona de no presi&#243;n de la palma &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>a&#41;&#46; De los 79 melanomas evaluados en el pie&#44; la zona de presi&#243;n fue la m&#225;s afectada con 52 casos &#40;65&#44;8&#37;&#41;&#44; en la cual&#44; el tal&#243;n fue la localizaci&#243;n con mayor n&#250;mero de melanomas&#46; En la zona de no presi&#243;n se presentaron 15 de las lesiones &#40;18&#44;9&#37;&#41; y en las u&#241;as 12 &#40;15&#44;1&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>b&#41;<span class="elsevierStyleItalic">&#46;</span></p><p id="par0080" class="elsevierStylePara elsevierViewall">La historia de trauma directo en la zona de presentaci&#243;n del melanoma fue mayor en los pacientes con lesiones en las u&#241;as&#46; Los melanomas invasores tuvieron mayor Breslow y presencia de ulceraci&#243;n en las zonas de presi&#243;n y en las u&#241;as que en las zonas de no presi&#243;n &#40;p &#61; 0&#44;006 y p &#61; 0&#44;018&#44; respectivamente&#41;&#46; El patr&#243;n de distribuci&#243;n del melanoma no se asoci&#243; con las dem&#225;s variables evaluadas &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0085" class="elsevierStylePara elsevierViewall">El MLA difiere de los melanomas en otras localizaciones por su presentaci&#243;n y factores de riesgo asociados<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#44;14</span></a>&#46; En nuestro estudio analizamos las caracter&#237;sticas cl&#237;nicas y patol&#243;gicas del MLA en 95 pacientes&#44; teniendo en cuenta su localizaci&#243;n&#46; Nuestro an&#225;lisis muestra que tanto en la mano como en el pie es m&#225;s frecuente la presencia de MLA en las zonas sometidas a mayor presi&#243;n&#44; lo cual adem&#225;s se asocia con una mayor profundidad tumoral&#44; en comparaci&#243;n con las zonas de no presi&#243;n&#46; La historia de trauma directo en el lugar de presentaci&#243;n del melanoma se dio con mayor frecuencia en los pacientes con lesiones en las u&#241;as&#44; la cual fue la zona en que m&#225;s se present&#243; ulceraci&#243;n&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">La edad media de los pacientes incluidos en el estudio fue menor a la descrita en algunos pa&#237;ses asi&#225;ticos<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;15&#44;16</span></a> y latinoamericanos<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">17&#44;18</span></a>&#46; La relaci&#243;n hombre&#58;mujer fue de 1&#58;1&#44;6&#44; lo cual es comparable con los datos de otros autores<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;18&#44;19</span></a> y&#44; contrario a lo publicado por Duarte<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">20</span></a> en Colombia&#44; se registraron m&#225;s casos de MLA en hombres que en mujeres&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La etiolog&#237;a del MLA contin&#250;a siendo poco clara&#46; Por su localizaci&#243;n&#44; la superficie acral es la que sufre menor da&#241;o por la luz del sol en el cuerpo&#44; de hecho&#44; un estudio mostr&#243; que los melanomas acrales tienen caracter&#237;sticas gen&#233;ticas diferentes&#44; con menor frecuencia de alteraciones inducidas por luz UV<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">21</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Tambi&#233;n es importante resaltar el hecho de que las palmas y plantas son &#225;reas m&#225;s hipopigmentadas&#44; en comparaci&#243;n con otras zonas del cuerpo&#44; incluso en razas oscuras&#46; Lo cual puede jugar un papel en la causa de los melanomas en la piel volar&#44; ya que como menciona Saida<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">22</span></a>&#44; es conocido que la melanina act&#250;a bloqueando la producci&#243;n de radicales libres&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Adem&#225;s se ha planteado que las zonas acrales est&#225;n expuestas a m&#225;s estr&#233;s mec&#225;nico&#44; en especial en &#225;reas delanteras y traseras del pie&#44; lo que puede llevar a un mayor da&#241;o en la piel a este nivel&#44; favoreciendo el desarrollo de melanomas<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; De hecho en la literatura se describe que la mayor&#237;a de los melanomas acrales se localizan en la planta<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;23&#44;24</span></a>&#44; lo cual podr&#237;a explicarse por el mayor estr&#233;s mec&#225;nico que ocurre en esta regi&#243;n&#44; en comparaci&#243;n con la palma<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a>&#46; Consistente con estos datos&#44; en nuestra serie la mayor&#237;a de los tumores se localizaron en los pies&#46; Sin embargo&#44; en algunos estudios se ha descrito que los melanomas subungulares se presentan con mayor frecuencia en los dedos de las manos que de los pies<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;25</span></a>&#44; diferente a nuestra casu&#237;stica donde tambi&#233;n los melanomas subungulares se presentaron m&#225;s en el pie&#44; principalmente en el primer dedo&#46; La u&#241;a del primer dedo tambi&#233;n fue la m&#225;s afectada de la mano &#40;datos no mostrados en las tablas&#41;&#44; lo que va en l&#237;nea con lo descrito hasta la fecha<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;26</span></a>&#46; M&#246;hrle y H&#228;fner sugieren que el trauma agudo o cr&#243;nico puede tener una relaci&#243;n con la patog&#233;nesis del melanoma acral&#44; ya que el pulgar y el primer dedo del pie son los dedos que m&#225;s se afectan por el trauma&#44; as&#237; como en los que m&#225;s se presenta el melanoma<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">En nuestros pacientes&#44; el porcentaje de antecedente de trauma directo previo en el lugar de aparici&#243;n del tumor fue superior a lo publicado en otros estudios<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;25</span></a>&#46; Al igual que lo descrito por Holman<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a>&#44; encontramos que el antecedente de trauma se present&#243; con mayor frecuencia en las lesiones de las u&#241;as que en las dem&#225;s zonas acrales&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Encontramos que el MLA se present&#243; con mayor frecuencia en las zonas de presi&#243;n de los pies&#44; principalmente el tal&#243;n&#44; lo cual coincide con lo publicado en diferentes poblaciones<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;16&#44;29</span></a>&#46; En un estudio realizado en la Cl&#237;nica Mayo no se encontr&#243; una diferencia significativa entre la distribuci&#243;n de la lesiones acrales&#44; seg&#250;n la zona de presi&#243;n y no presi&#243;n&#44; sin embargo&#44; encontraron que cerca de la mitad de los pacientes con melanomas en el arco del pie eran obesos&#44; lo que se pod&#237;a asociar con un aplanamiento del arco plantar&#44; as&#237; que excluyeron estos casos del an&#225;lisis&#44; encontrando una disminuci&#243;n en el valor de la p &#40;p &#61; 0&#44;39 vs&#46; p &#61; 0&#44;11&#41;&#44; aunque sin alcanzar la significaci&#243;n estad&#237;stica<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a>&#46; En nuestro estudio no se encontr&#243; una relaci&#243;n entre el IMC y la localizaci&#243;n del tumor&#44; a diferencia de Costello et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a>&#44; quienes asumen que en las personas obesas &#40;IMC &#62; 30&#41; se presenta un aplanamiento y posterior p&#233;rdida del arco plantar&#46; En nuestro trabajo no se comprob&#243; que esto ocurriera&#44; por lo cual no fue posible sacar estas conclusiones&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Nishiguchi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> evaluaron la diferencia de la distribuci&#243;n entre los nevus y los melanomas de la palma y los dedos de la mano&#44; encontrando que los nevus estaban presentes en el &#225;rea proximal al pliegue transversal distal de la palma&#44; en cambio&#44; los melanomas se presentaban en los pulpejos y distales al arco distal transverso de la palma&#44; que son zonas que se asocian con mayor presi&#243;n&#46; En nuestro estudio&#44; los melanomas de la mano tambi&#233;n predominaron en la zona volar de los dedos y en las u&#241;as&#46; Solo se encontraron dos casos ubicados en la eminencia hipotenar&#46; Estos hallazgos apoyan el hecho de que es &#250;til guiarse por la localizaci&#243;n para sospechar el diagn&#243;stico de malignidad cuando la lesi&#243;n se presenta en zonas m&#225;s distales&#44; en especial en los dedos y en las u&#241;as&#46; Sin embargo&#44; el hecho de que se presente en una zona de no presi&#243;n&#44; o m&#225;s proximal&#44; no puede excluir el diagn&#243;stico de melanoma como se mostr&#243; en nuestro estudio&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Dado que se ha descrito que el comportamiento de los melanomas que se presentan en las u&#241;as puede diferir en algunos aspectos al compararlo con los dem&#225;s melanomas acrales<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">25&#44;28</span></a>&#44; en nuestro caso analizamos los melanomas subungulares por separado&#44; encontrando que cuando se presentan melanomas invasores tienen tendencia a presentar una mayor profundidad tumoral&#44; mayor presencia de ulceraci&#243;n y un porcentaje superior de met&#225;stasis a ganglio&#44; en relaci&#243;n con las dem&#225;s localizaciones acrales&#46; Lo cual fue opuesto a lo publicado por Moon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">31</span></a>&#44; quienes encontraron que las u&#241;as presentaron menor ulceraci&#243;n que las lesiones de los dedos&#44; palmas y plantas&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">En cuanto a las caracter&#237;sticas histopatol&#243;gicas del tumor&#44; en nuestra serie la mayor&#237;a de las lesiones&#44; tanto de las manos como de los pies fueron <span class="elsevierStyleItalic">in situ</span>&#44; diferente a lo publicado por Barrera J&#225;come et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">18</span></a> y Costello et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a>&#44; donde los casos de melanoma acral no invasor corresponden a porcentajes bajos de un 8&#44;3&#37;&#46; Entre los melanomas invasores encontramos que el mayor porcentaje present&#243; un Breslow &#62; 4 mm&#44; comparable con lo descrito en poblaciones como Corea<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a>&#44; pero superior a lo encontrado en EE&#46; UU&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">23&#44;30</span></a> y Taiw&#225;n<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">A diferencia de lo que se ha publicado por otros autores&#44; quienes no encontraron una relaci&#243;n entre la localizaci&#243;n del tumor y el Breslow&#44; o la presencia de ulceraci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;25&#44;30</span></a>&#44; en nuestro caso s&#237; hubo una diferencia significativa entre la presencia de ulceraci&#243;n&#44; el Breslow y la historia de trauma al comparar los melanomas localizados en la zona de presi&#243;n&#44; la zona de no presi&#243;n y la u&#241;a&#46; Es interesante ver c&#243;mo entre los melanomas invasores el porcentaje se hizo mayor a medida que aument&#243; el Breslow en las lesiones localizadas en las zonas de presi&#243;n&#44; contrario a lo ocurrido en las zonas de no presi&#243;n&#44; donde el porcentaje de lesiones fue cada vez menor a medida que aumentaba la profundidad&#46; Sin embargo&#44; no se encontr&#243; una relaci&#243;n entre la localizaci&#243;n del MLA y el sexo&#44; el IMC&#44; las met&#225;stasis a ganglio ni el estadio tumoral&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Entre las limitantes que tiene nuestro estudio destacamos que algunos de los datos fueron obtenidos de fuente secundaria&#46; La variable de IMC fue calculada seg&#250;n el peso del paciente al momento de la encuesta telef&#243;nica&#44; debido a que en la historia cl&#237;nica no se contaba con el dato del peso y la talla al momento del diagn&#243;stico&#44; pudiendo diferir del IMC que ten&#237;an al momento del diagn&#243;stico del melanoma&#46; Adem&#225;s&#44; el n&#250;mero de lesiones en la mano fue bajo y fue dif&#237;cil realizar la clasificaci&#243;n de la palma en zona de presi&#243;n y no presi&#243;n&#44; ya que esto se puede ver afectado por la actividad que desarrolle el paciente&#44; lo que hace complejo sacar conclusiones de los melanomas localizados en esta zona&#46; Al ser casos recientes&#44; no fue posible evaluar la sobrevida a cinco a&#241;os de estos pacientes&#44; lo cual ser&#237;a interesante para poder compararla con la de otras poblaciones&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Los hallazgos de esta serie muestran que las zonas acrales que se consideran de presi&#243;n y aquellas con mayor predisposici&#243;n al trauma directo como la u&#241;a del <span class="elsevierStyleItalic">hallux</span> y el pulgar tienen una relaci&#243;n con el desarrollo de MLA&#44; sugiriendo que tanto el estr&#233;s agudo como el cr&#243;nico pueden asociarse con el desarrollo de este subtipo de melanoma&#46; Aunque en nuestro estudio la localizaci&#243;n de la lesi&#243;n se asoci&#243; de manera significativa al Breslow&#44; no hubo una relaci&#243;n con el estadio tumoral&#44; lo cual podr&#237;a indicar que la localizaci&#243;n no afecta el pron&#243;stico de los pacientes&#46; Sin embargo&#44; hacen falta estudios que incluyan un mayor n&#250;mero de casos&#44; en especial en la mano&#44; para analizar las diferencias entre la localizaci&#243;n y la sobrevida de estas personas&#46; Adem&#225;s&#44; ser&#237;a importante investigar las labores que realizan los pacientes&#44; y que pueden implicar mayor estr&#233;s mec&#225;nico en las zonas acrales&#44; para relacionar dichas actividades con el desarrollo del MLA&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; la localizaci&#243;n predominante de los MLA en zonas de presi&#243;n&#44; consistente con los hallazgos de otros estudios&#44; apoya la hip&#243;tesis de que el estr&#233;s mec&#225;nico puede jugar un papel en la patog&#233;nesis de este tipo de tumor&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Financiaci&#243;n</span><p id="par0155" class="elsevierStylePara elsevierViewall">Este trabajo no ha recibido ning&#250;n tipo de financiaci&#243;n&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicto de intereses</span><p id="par0160" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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            0 => "Melanoma lentiginoso acral"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Antecedentes y objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">El melanoma lentiginoso acral &#40;MLA&#41; se presenta en zonas con poca exposici&#243;n a la radiaci&#243;n ultravioleta&#46; Se ha planteado que el trauma cr&#243;nico puede predisponer a su desarrollo&#46; El objetivo del presente estudio fue relacionar la presencia del MLA y sus caracter&#237;sticas con las zonas acrales que se consideran de presi&#243;n y de no presi&#243;n&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio observacional&#44; descriptivo&#44; con intenci&#243;n anal&#237;tica&#46; Se recogieron los datos de 95 pacientes con diagn&#243;stico de MLA evaluados en la Fundaci&#243;n Cl&#237;nica Vida en Medell&#237;n&#44; Colombia&#44; entre enero de 2016 y agosto de 2020&#46; Se recolectaron variables demogr&#225;ficas&#44; histol&#243;gicas y cl&#237;nicas del tumor&#44; las cuales se analizaron en dos grupos&#44; seg&#250;n si estaba sometida a fuerzas de presi&#243;n o no&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 95 pacientes con MLA &#40;36 hombres y 59 mujeres&#41;&#44; con una mediana de edad de 59 a&#241;os&#46; Se presentaron m&#225;s melanomas en las zonas de presi&#243;n que de no presi&#243;n &#40;58 &#91;61&#37;&#93; vs&#46; 17 &#91;17&#44;8&#37;&#93;&#41;&#46; Se refiri&#243; la existencia de un trauma directo previo en 18&#44;9&#37; de los casos&#44; el cual fue m&#225;s frecuente en las lesiones de las u&#241;as &#40;p &#61; 0&#44;025&#41;&#46; Los melanomas invasores tuvieron un mayor Breslow &#40;p &#61; 0&#44;006&#41; y presencia de ulceraci&#243;n &#40;p &#61; 0&#44;018&#41; en las zonas de presi&#243;n y en las u&#241;as que en las zonas de no presi&#243;n&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El MLA es m&#225;s frecuente en zonas de presi&#243;n que de no presi&#243;n&#44; tanto en la mano como en el pie&#46; Esto apoya la hip&#243;tesis de que el estr&#233;s mec&#225;nico puede jugar un papel en la patog&#233;nesis de este tipo de tumor&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background and objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Acral lentiginous melanoma &#40;ALM&#41; arises in areas that are not generally exposed to UV radiation&#46; Chronic trauma has been hypothesized to play a role in the development of this tumor&#46; The aim of this study was to analyze the association between the presence and characteristics of ALM and location in stress- and non&#8211;stress-bearing areas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Observational&#44; descriptive analysis&#46; For 95 patients with ALM evaluated at Fundaci&#243;n Cl&#237;nica Vida in Medellin&#44; Colombia between January 2016 and August 2020 we collected demographic&#44; histologic and clinical variables and assigned the patients to 2 groups depending on whether their tumor was located in a stress-bearing area or not&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ninety-five patients &#40;36 men and 59 women&#41; with a median age of 59 years were studied&#46; ALMs were more common in stress-bearing areas than in non&#8211;stress-bearing areas &#40;58 &#91;61&#37;&#93; vs&#46; 17 &#91;17&#46;8&#37;&#93;&#41;&#46; A history of direct trauma at the site of the tumor was reported in 18&#46;9&#37; of the cases &#40;p &#61; &#46;025&#41; and was most common in patients with nail lesions&#46; Invasive ALMs in stress-bearing areas had a greater Breslow thickness &#40;p &#61; &#46;006&#41; and higher ulceration rates than those in non&#8211;stress-bearing areas &#40;p &#61; &#46;018&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ALM on both the feet and hands is more common in stress-bearing areas&#46; Our findings support the hypothesis that mechanical stress may have a pathogenic role in ALM&#46;</p></span>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#37;&#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"><span class="elsevierStyleHsp" style=""></span>Peso normal&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\ttable-entry\n
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                  \t\t\t\t\ttable-entry\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\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sin informaci&#243;n&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">9 &#40;9&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T1&#58; &#8804; 1&#44;0 mm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T4&#58; &#62; 4&#44;0 mm&nbsp;\t\t\t\t\t\t\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="elsevierStyleHsp" style=""></span>Ulceraci&#243;n<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&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"><span class="elsevierStyleHsp" style=""></span>Presente&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">7 &#40;63&#44;6&#37;&#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">19 &#40;40&#44;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"><span class="elsevierStyleHsp" style=""></span>Ausente&nbsp;\t\t\t\t\t\t\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">4 &#40;36&#44;3&#37;&#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\ttop\n
                  \t\t\t\t">28 &#40;59&#44;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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Met&#225;stasis ganglionar<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;18&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;27&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;16&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III&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">13 &#40;16&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sin informaci&#243;n&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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                  \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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;025&nbsp;\t\t\t\t\t\t\n
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                  \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">8 &#40;13&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;11&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;18&#44;9&#37;&#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  " 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
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                  \t\t\t\t">50 &#40;86&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15 &#40;88&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;60&#37;&#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">77 &#40;81&#44;1&#37;&#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></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">Breslow</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
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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><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;006&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><span class="elsevierStyleItalic">In Situ</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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;41&#44;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">6 &#40;35&#44;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">7 &#40;35&#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;38&#44;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="" 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>&#8804; 1 mm&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;8&#44;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">6 &#40;35&#44;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&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&#44;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="" 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></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>&#62; 1&#44;0-2&#44;0 mm&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 &#40;12&#44;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;23&#44;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">1 &#40;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">12 &#40;12&#44;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="" 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></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>&#62; 2&#44;0-4&#44;0 mm&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;19&#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;5&#44;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">5 &#40;25&#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;17&#44;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="" 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></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>&#62; 4&#44;0 mm&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;19&#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&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 &#40;35&#37;&#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">18 &#40;18&#44;9&#37;&#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></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">Ulceraci&#243;n</span><a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;</a>&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  " 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&#44;018&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">12 &#40;35&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\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">3 &#40;27&#44;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">10 &#40;76&#44;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">25 &#40;43&#44;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="" 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></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">22 &#40;64&#44;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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;72&#44;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">3 &#40;23&#44;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
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                  \t\t\t\t">33 &#40;56&#44;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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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ORIGINAL
Características del melanoma lentiginoso acral según su relación con la presión. Estudio retrospectivo de 95 pacientes
Characteristics of Acral Lentiginous Melanoma According to Location in Stress- or Non–Stress-Bearing Areas: A Retrospective Study of 95 Patients
J. Arango Abisaada,
Corresponding author
juanitaarangoabisaad@gmail.com

Autor para correspondencia.
, V. Arciniegas Grisalesa, Á. Londoño Garcíaa,b, E.M. Vasquez Trespalaciosc, G. Jiménez Calfata,b, J.M. Cuello Lópezb
a Servicio de Dermatología, Universidad CES, Medellín, Colombia
b Servicio de Oncología, Fundación Clínica Vida, Medellín, Colombia
c Epidemiología, Universidad CES, Medellín, Colombia
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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 melanoma lentiginoso acral &#40;MLA&#41; es un subtipo de melanoma que se da en las palmas&#44; las plantas y en el lecho ungular&#46; Aunque la incidencia es igual en todas las poblaciones&#44; su proporci&#243;n en el total de melanomas var&#237;a del 1-7&#37; en cauc&#225;sicos<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">1</span></a>&#44; al 15&#37; en hispanos<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">2</span></a>&#44; entre el 45-58&#37; en asi&#225;ticos y el 70&#37; en la raza negra<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El comportamiento de este tumor es diferente al de los melanomas en otras localizaciones&#46; Se han descrito factores de riesgo espec&#237;ficos&#44; ya que el MLA guarda una menor relaci&#243;n con los fototipos claros o la preexistencia de nevus melanoc&#237;ticos y tiende a presentarse en zonas con poca exposici&#243;n a la radiaci&#243;n ultravioleta &#40;RUV&#41;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#8211;7</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Se ha planteado que el trauma cr&#243;nico en &#225;reas acrales puede predisponer a que se presente este tipo de tumor<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a>&#46; Esto se ha sugerido por su presentaci&#243;n m&#225;s frecuente en las zonas de mayor estr&#233;s mec&#225;nico&#44; las &#225;reas delanteras y traseras del pie&#44; sugiriendo que esto ser&#237;a debido a que la presi&#243;n ocasionar&#237;a un mayor da&#241;o de la piel y a su vez a una mayor propensi&#243;n a desarrollar MLA&#44; en comparaci&#243;n con las dem&#225;s zonas consideradas como de no apoyo<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; A pesar de haber menos estudios de MLA en las manos&#44; tambi&#233;n se han observado hallazgos que apoyan esta hip&#243;tesis al encontrar que los melanomas&#44; contrario a lo que ocurre con los nevus&#44; no se localizan en el &#225;rea proximal de la palma sino en los pulpejos y en la zona distal de la palma&#44; donde se suele presentar un mayor estr&#233;s mec&#225;nico<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo del presente estudio fue relacionar la presencia del MLA y sus caracter&#237;sticas con las zonas acrales que se consideran de presi&#243;n y de no presi&#243;n&#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 realiz&#243; un estudio observacional retrospectivo siguiendo las recomendaciones de la gu&#237;a Strobe<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a>&#46; Se recogieron los datos de pacientes con un diagn&#243;stico de MLA que fueron evaluados en la Fundaci&#243;n Cl&#237;nica Vida en Medell&#237;n&#44; Colombia&#44; centro de referencia de la ciudad para el tratamiento del c&#225;ncer de piel&#44; en el per&#237;odo comprendido entre enero del a&#241;o 2016 y agosto de 2020&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los datos se obtuvieron de una fuente de informaci&#243;n mixta por medio de las historias cl&#237;nicas electr&#243;nicas de los pacientes y se realiz&#243; un cuestionario por medio telef&#243;nico para completar la informaci&#243;n faltante&#46; La localizaci&#243;n de la lesi&#243;n fue especificada a trav&#233;s de una imagen enviada al paciente&#44; donde se observaba la extremidad afectada dividida por zonas para que este se&#241;alara el &#225;rea afectada&#44; lo cual permiti&#243; una clasificaci&#243;n objetiva&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Los criterios de inclusi&#243;n fueron los pacientes con diagn&#243;stico de MLA confirmado por histopatolog&#237;a&#44; sin met&#225;stasis a distancia&#44; los cuales fueron excluidos ya que el evento se present&#243; en cuatro casos de los cuales no se contaba con la informaci&#243;n completa del estadio histol&#243;gico del melanoma primario&#46; Se excluyeron los pacientes que hab&#237;an fallecido en el momento del estudio y con quienes no fue posible comunicarse para realizar la encuesta por v&#237;a telef&#243;nica&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">El estudio y todos sus procedimientos fueron aprobados por el Comit&#233; de &#201;tica de la Fundaci&#243;n Cl&#237;nica Vida&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se recogieron variables demogr&#225;ficas como edad y sexo&#46; Se interrog&#243; si exist&#237;a el antecedente de traumatismo directo en la zona del tumor y la dominancia lateral &#40;diestro&#44; zurdo&#41;&#46; Adem&#225;s&#44; al momento de hacer la encuesta telef&#243;nica se registr&#243; el peso y la talla para calcular el &#237;ndice de masa corporal &#40;IMC&#41;&#44; el cual se categoriz&#243; seg&#250;n la clasificaci&#243;n de sobrepeso y obesidad propuesta por el comit&#233; de expertos de la Organizaci&#243;n Mundial de la Salud &#40;OMS&#41;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">La variable dependiente fue la localizaci&#243;n seg&#250;n si estaba sometida a fuerzas de presi&#243;n o no &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; En la cara volar de la mano&#44; se consideraron como zonas de presi&#243;n los dedos y la cabeza de los metacarpianos&#44; ya que son las que sufren m&#225;s estr&#233;s mec&#225;nico con los agarres y donde se suelen presentar m&#225;s lesiones como callos y ampollas<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">8&#44;11&#44;12</span></a>&#46; Por consenso de expertos&#44; el resto de la palma se clasific&#243; como zona de no presi&#243;n&#46; Las u&#241;as se analizaron por separado&#46; En la superficie plantar&#44; de acuerdo con el grado de estr&#233;s mec&#225;nico&#44; se clasific&#243; como zona de presi&#243;n a la cara plantar de los dedos&#44; el antepi&#233;&#44; el mediopi&#233; lateral y el tal&#243;n&#46; El arco plantar se defini&#243; como zona de no presi&#243;n&#46; Las u&#241;as se analizaron por separado&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Se consideraron las siguientes variables independientes&#46; En cuanto a las caracter&#237;sticas tumorales se evalu&#243; su localizaci&#243;n&#44; lateralidad &#40;derecho&#59; izquierdo&#41;&#44; datos histopatol&#243;gicos que incluyeron la profundidad del tumor &#40;Breslow&#58; recogido como variable cualitativa ordinal con intervalos de espesor de T0-T4&#41; y la presencia de ulceraci&#243;n&#46; Tambi&#233;n se evalu&#243; el compromiso metast&#225;sico ganglionar y se clasific&#243; el tumor seg&#250;n el sistema de estadiaje propuesto por el <span class="elsevierStyleItalic">American Joint Committee on Cancer</span> &#40;AJCC&#41; en la octava edici&#243;n<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Las variables categ&#243;ricas se describieron utilizando una distribuci&#243;n de frecuencia absoluta y relativa&#44; las variables cuantitativas utilizando medidas de tendencia central y dispersi&#243;n&#46; La asociaci&#243;n entre variables cualitativas independientes y la variable dependiente se evalu&#243; mediante la prueba de &#967;<span class="elsevierStyleSup">2</span> o prueba exacta de Fisher&#44; cuando la frecuencia esperada fue menor del 5&#37;&#46; Los an&#225;lisis estad&#237;sticos se realizaron con el programa estad&#237;stico SPSS versi&#243;n 21 &#40;IBM Corp&#46;&#44; Armonk&#44; NY&#44; EE&#46; UU&#46;&#41;&#46; La significaci&#243;n estad&#237;stica se estableci&#243; para un valor de p inferior al 5&#37;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0065" class="elsevierStylePara elsevierViewall">Se incluyeron un total de 95 pacientes con MLA &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#44; mediana de edad &#40;rango intercuart&#237;lico &#91;RIQ&#93;&#41; de 59 a&#241;os &#40;50-70&#41;&#44; de los cuales&#44; 59 &#40;62&#44;1&#37;&#41; fueron de sexo femenino&#46; Se report&#243; trauma directo previo en la zona de presentaci&#243;n del melanoma en 18 &#40;18&#44;9&#37;&#41; de los casos &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">De las lesiones evaluadas&#44; 16 &#40;16&#44;8&#37;&#41; se presentaron en las manos y 79 &#40;83&#44;1&#37;&#41; en los pies&#46; Aunque en las manos hubo un leve predominio por el lado derecho &#40;56&#44;2 derecho vs&#46; 43&#44;7&#37; izquierdo&#41;&#44; en los pies hubo m&#225;s melanomas acrales en el lado izquierdo &#40;53&#44;1 izquierdo vs&#46; 46&#44;8&#37; derecho&#41;&#46; La mayor&#237;a de las lesiones fueron <span class="elsevierStyleItalic">in situ</span> &#40;37 &#91;38&#44;9&#37;&#93;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">De los 16 melanomas evaluados en la mano&#44; la mitad se localizaron en las u&#241;as&#44; 6 &#40;37&#44;5&#37;&#41; en la zona de presi&#243;n y 2 &#40;12&#44;5&#37;&#41; en la zona de no presi&#243;n de la palma &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>a&#41;&#46; De los 79 melanomas evaluados en el pie&#44; la zona de presi&#243;n fue la m&#225;s afectada con 52 casos &#40;65&#44;8&#37;&#41;&#44; en la cual&#44; el tal&#243;n fue la localizaci&#243;n con mayor n&#250;mero de melanomas&#46; En la zona de no presi&#243;n se presentaron 15 de las lesiones &#40;18&#44;9&#37;&#41; y en las u&#241;as 12 &#40;15&#44;1&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>b&#41;<span class="elsevierStyleItalic">&#46;</span></p><p id="par0080" class="elsevierStylePara elsevierViewall">La historia de trauma directo en la zona de presentaci&#243;n del melanoma fue mayor en los pacientes con lesiones en las u&#241;as&#46; Los melanomas invasores tuvieron mayor Breslow y presencia de ulceraci&#243;n en las zonas de presi&#243;n y en las u&#241;as que en las zonas de no presi&#243;n &#40;p &#61; 0&#44;006 y p &#61; 0&#44;018&#44; respectivamente&#41;&#46; El patr&#243;n de distribuci&#243;n del melanoma no se asoci&#243; con las dem&#225;s variables evaluadas &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0085" class="elsevierStylePara elsevierViewall">El MLA difiere de los melanomas en otras localizaciones por su presentaci&#243;n y factores de riesgo asociados<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#44;14</span></a>&#46; En nuestro estudio analizamos las caracter&#237;sticas cl&#237;nicas y patol&#243;gicas del MLA en 95 pacientes&#44; teniendo en cuenta su localizaci&#243;n&#46; Nuestro an&#225;lisis muestra que tanto en la mano como en el pie es m&#225;s frecuente la presencia de MLA en las zonas sometidas a mayor presi&#243;n&#44; lo cual adem&#225;s se asocia con una mayor profundidad tumoral&#44; en comparaci&#243;n con las zonas de no presi&#243;n&#46; La historia de trauma directo en el lugar de presentaci&#243;n del melanoma se dio con mayor frecuencia en los pacientes con lesiones en las u&#241;as&#44; la cual fue la zona en que m&#225;s se present&#243; ulceraci&#243;n&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">La edad media de los pacientes incluidos en el estudio fue menor a la descrita en algunos pa&#237;ses asi&#225;ticos<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;15&#44;16</span></a> y latinoamericanos<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">17&#44;18</span></a>&#46; La relaci&#243;n hombre&#58;mujer fue de 1&#58;1&#44;6&#44; lo cual es comparable con los datos de otros autores<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;18&#44;19</span></a> y&#44; contrario a lo publicado por Duarte<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">20</span></a> en Colombia&#44; se registraron m&#225;s casos de MLA en hombres que en mujeres&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La etiolog&#237;a del MLA contin&#250;a siendo poco clara&#46; Por su localizaci&#243;n&#44; la superficie acral es la que sufre menor da&#241;o por la luz del sol en el cuerpo&#44; de hecho&#44; un estudio mostr&#243; que los melanomas acrales tienen caracter&#237;sticas gen&#233;ticas diferentes&#44; con menor frecuencia de alteraciones inducidas por luz UV<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">21</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Tambi&#233;n es importante resaltar el hecho de que las palmas y plantas son &#225;reas m&#225;s hipopigmentadas&#44; en comparaci&#243;n con otras zonas del cuerpo&#44; incluso en razas oscuras&#46; Lo cual puede jugar un papel en la causa de los melanomas en la piel volar&#44; ya que como menciona Saida<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">22</span></a>&#44; es conocido que la melanina act&#250;a bloqueando la producci&#243;n de radicales libres&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Adem&#225;s se ha planteado que las zonas acrales est&#225;n expuestas a m&#225;s estr&#233;s mec&#225;nico&#44; en especial en &#225;reas delanteras y traseras del pie&#44; lo que puede llevar a un mayor da&#241;o en la piel a este nivel&#44; favoreciendo el desarrollo de melanomas<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; De hecho en la literatura se describe que la mayor&#237;a de los melanomas acrales se localizan en la planta<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;23&#44;24</span></a>&#44; lo cual podr&#237;a explicarse por el mayor estr&#233;s mec&#225;nico que ocurre en esta regi&#243;n&#44; en comparaci&#243;n con la palma<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a>&#46; Consistente con estos datos&#44; en nuestra serie la mayor&#237;a de los tumores se localizaron en los pies&#46; Sin embargo&#44; en algunos estudios se ha descrito que los melanomas subungulares se presentan con mayor frecuencia en los dedos de las manos que de los pies<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;25</span></a>&#44; diferente a nuestra casu&#237;stica donde tambi&#233;n los melanomas subungulares se presentaron m&#225;s en el pie&#44; principalmente en el primer dedo&#46; La u&#241;a del primer dedo tambi&#233;n fue la m&#225;s afectada de la mano &#40;datos no mostrados en las tablas&#41;&#44; lo que va en l&#237;nea con lo descrito hasta la fecha<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;26</span></a>&#46; M&#246;hrle y H&#228;fner sugieren que el trauma agudo o cr&#243;nico puede tener una relaci&#243;n con la patog&#233;nesis del melanoma acral&#44; ya que el pulgar y el primer dedo del pie son los dedos que m&#225;s se afectan por el trauma&#44; as&#237; como en los que m&#225;s se presenta el melanoma<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">En nuestros pacientes&#44; el porcentaje de antecedente de trauma directo previo en el lugar de aparici&#243;n del tumor fue superior a lo publicado en otros estudios<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;25</span></a>&#46; Al igual que lo descrito por Holman<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a>&#44; encontramos que el antecedente de trauma se present&#243; con mayor frecuencia en las lesiones de las u&#241;as que en las dem&#225;s zonas acrales&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Encontramos que el MLA se present&#243; con mayor frecuencia en las zonas de presi&#243;n de los pies&#44; principalmente el tal&#243;n&#44; lo cual coincide con lo publicado en diferentes poblaciones<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;16&#44;29</span></a>&#46; En un estudio realizado en la Cl&#237;nica Mayo no se encontr&#243; una diferencia significativa entre la distribuci&#243;n de la lesiones acrales&#44; seg&#250;n la zona de presi&#243;n y no presi&#243;n&#44; sin embargo&#44; encontraron que cerca de la mitad de los pacientes con melanomas en el arco del pie eran obesos&#44; lo que se pod&#237;a asociar con un aplanamiento del arco plantar&#44; as&#237; que excluyeron estos casos del an&#225;lisis&#44; encontrando una disminuci&#243;n en el valor de la p &#40;p &#61; 0&#44;39 vs&#46; p &#61; 0&#44;11&#41;&#44; aunque sin alcanzar la significaci&#243;n estad&#237;stica<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a>&#46; En nuestro estudio no se encontr&#243; una relaci&#243;n entre el IMC y la localizaci&#243;n del tumor&#44; a diferencia de Costello et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a>&#44; quienes asumen que en las personas obesas &#40;IMC &#62; 30&#41; se presenta un aplanamiento y posterior p&#233;rdida del arco plantar&#46; En nuestro trabajo no se comprob&#243; que esto ocurriera&#44; por lo cual no fue posible sacar estas conclusiones&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Nishiguchi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> evaluaron la diferencia de la distribuci&#243;n entre los nevus y los melanomas de la palma y los dedos de la mano&#44; encontrando que los nevus estaban presentes en el &#225;rea proximal al pliegue transversal distal de la palma&#44; en cambio&#44; los melanomas se presentaban en los pulpejos y distales al arco distal transverso de la palma&#44; que son zonas que se asocian con mayor presi&#243;n&#46; En nuestro estudio&#44; los melanomas de la mano tambi&#233;n predominaron en la zona volar de los dedos y en las u&#241;as&#46; Solo se encontraron dos casos ubicados en la eminencia hipotenar&#46; Estos hallazgos apoyan el hecho de que es &#250;til guiarse por la localizaci&#243;n para sospechar el diagn&#243;stico de malignidad cuando la lesi&#243;n se presenta en zonas m&#225;s distales&#44; en especial en los dedos y en las u&#241;as&#46; Sin embargo&#44; el hecho de que se presente en una zona de no presi&#243;n&#44; o m&#225;s proximal&#44; no puede excluir el diagn&#243;stico de melanoma como se mostr&#243; en nuestro estudio&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Dado que se ha descrito que el comportamiento de los melanomas que se presentan en las u&#241;as puede diferir en algunos aspectos al compararlo con los dem&#225;s melanomas acrales<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">25&#44;28</span></a>&#44; en nuestro caso analizamos los melanomas subungulares por separado&#44; encontrando que cuando se presentan melanomas invasores tienen tendencia a presentar una mayor profundidad tumoral&#44; mayor presencia de ulceraci&#243;n y un porcentaje superior de met&#225;stasis a ganglio&#44; en relaci&#243;n con las dem&#225;s localizaciones acrales&#46; Lo cual fue opuesto a lo publicado por Moon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">31</span></a>&#44; quienes encontraron que las u&#241;as presentaron menor ulceraci&#243;n que las lesiones de los dedos&#44; palmas y plantas&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">En cuanto a las caracter&#237;sticas histopatol&#243;gicas del tumor&#44; en nuestra serie la mayor&#237;a de las lesiones&#44; tanto de las manos como de los pies fueron <span class="elsevierStyleItalic">in situ</span>&#44; diferente a lo publicado por Barrera J&#225;come et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">18</span></a> y Costello et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a>&#44; donde los casos de melanoma acral no invasor corresponden a porcentajes bajos de un 8&#44;3&#37;&#46; Entre los melanomas invasores encontramos que el mayor porcentaje present&#243; un Breslow &#62; 4 mm&#44; comparable con lo descrito en poblaciones como Corea<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a>&#44; pero superior a lo encontrado en EE&#46; UU&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">23&#44;30</span></a> y Taiw&#225;n<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">A diferencia de lo que se ha publicado por otros autores&#44; quienes no encontraron una relaci&#243;n entre la localizaci&#243;n del tumor y el Breslow&#44; o la presencia de ulceraci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;25&#44;30</span></a>&#44; en nuestro caso s&#237; hubo una diferencia significativa entre la presencia de ulceraci&#243;n&#44; el Breslow y la historia de trauma al comparar los melanomas localizados en la zona de presi&#243;n&#44; la zona de no presi&#243;n y la u&#241;a&#46; Es interesante ver c&#243;mo entre los melanomas invasores el porcentaje se hizo mayor a medida que aument&#243; el Breslow en las lesiones localizadas en las zonas de presi&#243;n&#44; contrario a lo ocurrido en las zonas de no presi&#243;n&#44; donde el porcentaje de lesiones fue cada vez menor a medida que aumentaba la profundidad&#46; Sin embargo&#44; no se encontr&#243; una relaci&#243;n entre la localizaci&#243;n del MLA y el sexo&#44; el IMC&#44; las met&#225;stasis a ganglio ni el estadio tumoral&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Entre las limitantes que tiene nuestro estudio destacamos que algunos de los datos fueron obtenidos de fuente secundaria&#46; La variable de IMC fue calculada seg&#250;n el peso del paciente al momento de la encuesta telef&#243;nica&#44; debido a que en la historia cl&#237;nica no se contaba con el dato del peso y la talla al momento del diagn&#243;stico&#44; pudiendo diferir del IMC que ten&#237;an al momento del diagn&#243;stico del melanoma&#46; Adem&#225;s&#44; el n&#250;mero de lesiones en la mano fue bajo y fue dif&#237;cil realizar la clasificaci&#243;n de la palma en zona de presi&#243;n y no presi&#243;n&#44; ya que esto se puede ver afectado por la actividad que desarrolle el paciente&#44; lo que hace complejo sacar conclusiones de los melanomas localizados en esta zona&#46; Al ser casos recientes&#44; no fue posible evaluar la sobrevida a cinco a&#241;os de estos pacientes&#44; lo cual ser&#237;a interesante para poder compararla con la de otras poblaciones&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Los hallazgos de esta serie muestran que las zonas acrales que se consideran de presi&#243;n y aquellas con mayor predisposici&#243;n al trauma directo como la u&#241;a del <span class="elsevierStyleItalic">hallux</span> y el pulgar tienen una relaci&#243;n con el desarrollo de MLA&#44; sugiriendo que tanto el estr&#233;s agudo como el cr&#243;nico pueden asociarse con el desarrollo de este subtipo de melanoma&#46; Aunque en nuestro estudio la localizaci&#243;n de la lesi&#243;n se asoci&#243; de manera significativa al Breslow&#44; no hubo una relaci&#243;n con el estadio tumoral&#44; lo cual podr&#237;a indicar que la localizaci&#243;n no afecta el pron&#243;stico de los pacientes&#46; Sin embargo&#44; hacen falta estudios que incluyan un mayor n&#250;mero de casos&#44; en especial en la mano&#44; para analizar las diferencias entre la localizaci&#243;n y la sobrevida de estas personas&#46; Adem&#225;s&#44; ser&#237;a importante investigar las labores que realizan los pacientes&#44; y que pueden implicar mayor estr&#233;s mec&#225;nico en las zonas acrales&#44; para relacionar dichas actividades con el desarrollo del MLA&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; la localizaci&#243;n predominante de los MLA en zonas de presi&#243;n&#44; consistente con los hallazgos de otros estudios&#44; apoya la hip&#243;tesis de que el estr&#233;s mec&#225;nico puede jugar un papel en la patog&#233;nesis de este tipo de tumor&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Financiaci&#243;n</span><p id="par0155" class="elsevierStylePara elsevierViewall">Este trabajo no ha recibido ning&#250;n tipo de financiaci&#243;n&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicto de intereses</span><p id="par0160" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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            0 => "Melanoma lentiginoso acral"
            1 => "Subungular"
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            3 => "Factores de riesgo"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Antecedentes y objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">El melanoma lentiginoso acral &#40;MLA&#41; se presenta en zonas con poca exposici&#243;n a la radiaci&#243;n ultravioleta&#46; Se ha planteado que el trauma cr&#243;nico puede predisponer a su desarrollo&#46; El objetivo del presente estudio fue relacionar la presencia del MLA y sus caracter&#237;sticas con las zonas acrales que se consideran de presi&#243;n y de no presi&#243;n&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio observacional&#44; descriptivo&#44; con intenci&#243;n anal&#237;tica&#46; Se recogieron los datos de 95 pacientes con diagn&#243;stico de MLA evaluados en la Fundaci&#243;n Cl&#237;nica Vida en Medell&#237;n&#44; Colombia&#44; entre enero de 2016 y agosto de 2020&#46; Se recolectaron variables demogr&#225;ficas&#44; histol&#243;gicas y cl&#237;nicas del tumor&#44; las cuales se analizaron en dos grupos&#44; seg&#250;n si estaba sometida a fuerzas de presi&#243;n o no&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 95 pacientes con MLA &#40;36 hombres y 59 mujeres&#41;&#44; con una mediana de edad de 59 a&#241;os&#46; Se presentaron m&#225;s melanomas en las zonas de presi&#243;n que de no presi&#243;n &#40;58 &#91;61&#37;&#93; vs&#46; 17 &#91;17&#44;8&#37;&#93;&#41;&#46; Se refiri&#243; la existencia de un trauma directo previo en 18&#44;9&#37; de los casos&#44; el cual fue m&#225;s frecuente en las lesiones de las u&#241;as &#40;p &#61; 0&#44;025&#41;&#46; Los melanomas invasores tuvieron un mayor Breslow &#40;p &#61; 0&#44;006&#41; y presencia de ulceraci&#243;n &#40;p &#61; 0&#44;018&#41; en las zonas de presi&#243;n y en las u&#241;as que en las zonas de no presi&#243;n&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El MLA es m&#225;s frecuente en zonas de presi&#243;n que de no presi&#243;n&#44; tanto en la mano como en el pie&#46; Esto apoya la hip&#243;tesis de que el estr&#233;s mec&#225;nico puede jugar un papel en la patog&#233;nesis de este tipo de tumor&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background and objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Acral lentiginous melanoma &#40;ALM&#41; arises in areas that are not generally exposed to UV radiation&#46; Chronic trauma has been hypothesized to play a role in the development of this tumor&#46; The aim of this study was to analyze the association between the presence and characteristics of ALM and location in stress- and non&#8211;stress-bearing areas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Observational&#44; descriptive analysis&#46; For 95 patients with ALM evaluated at Fundaci&#243;n Cl&#237;nica Vida in Medellin&#44; Colombia between January 2016 and August 2020 we collected demographic&#44; histologic and clinical variables and assigned the patients to 2 groups depending on whether their tumor was located in a stress-bearing area or not&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ninety-five patients &#40;36 men and 59 women&#41; with a median age of 59 years were studied&#46; ALMs were more common in stress-bearing areas than in non&#8211;stress-bearing areas &#40;58 &#91;61&#37;&#93; vs&#46; 17 &#91;17&#46;8&#37;&#93;&#41;&#46; A history of direct trauma at the site of the tumor was reported in 18&#46;9&#37; of the cases &#40;p &#61; &#46;025&#41; and was most common in patients with nail lesions&#46; Invasive ALMs in stress-bearing areas had a greater Breslow thickness &#40;p &#61; &#46;006&#41; and higher ulceration rates than those in non&#8211;stress-bearing areas &#40;p &#61; &#46;018&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ALM on both the feet and hands is more common in stress-bearing areas&#46; Our findings support the hypothesis that mechanical stress may have a pathogenic role in ALM&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Femenino&nbsp;\t\t\t\t\t\t\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
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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">Edad&#44; a&#241;os</span>&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\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\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">77 &#40;81&#37;&#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\ttop\n
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                  \t\t\t\t">1 &#40;1&#37;&#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  " 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
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                  \t\t\t\t">9 &#40;9&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T1&#58; &#8804; 1&#44;0 mm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T2&#58; &#62; 1&#44;0-2&#44;0 mm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T4&#58; &#62; 4&#44;0 mm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15 &#40;18&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\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="elsevierStyleHsp" style=""></span>Ulceraci&#243;n<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;n &#61; 47&#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"><span class="elsevierStyleHsp" style=""></span>Presente&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">7 &#40;63&#44;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">19 &#40;40&#44;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"><span class="elsevierStyleHsp" style=""></span>Ausente&nbsp;\t\t\t\t\t\t\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">4 &#40;36&#44;3&#37;&#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\ttop\n
                  \t\t\t\t">28 &#40;59&#44;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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Met&#225;stasis ganglionar<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;18&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;27&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sin informaci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Historia de trauma</span>&nbsp;\t\t\t\t\t\t\n
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                  \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  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&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"><span class="elsevierStyleItalic">Breslow</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;006&nbsp;\t\t\t\t\t\t\n
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                  \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><span class="elsevierStyleItalic">In Situ</span>&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
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                  \t\t\t\t">24 &#40;41&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;35&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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>&#8804; 1 mm&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">5 &#40;8&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;35&#44;3&#37;&#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 ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62; 1&#44;0-2&#44;0 mm&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">7 &#40;12&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;23&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;12&#44;6&#37;&#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></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \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>&#62; 2&#44;0-4&#44;0 mm&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">1 &#40;5&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17 &#40;17&#44;9&#37;&#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></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62; 4&#44;0 mm&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">18 &#40;18&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\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  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \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></tr></tbody></table>
                  """
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                0 => "xTab2849448.png"
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            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Se incluyeron solo los pacientes con melanoma invasor &#40;n &#61; 58&#41;&#46;</p> <p class="elsevierStyleNotepara" id="npar0020">IMC&#58; &#237;ndice de masa corporal&#46;</p>"
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          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Relaci&#243;n entre las caracter&#237;sticas y la localizaci&#243;n del tumor</p>"
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      "titulo" => "Bibliograf&#237;a"
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                      "titulo" => "Acral lentiginous melanoma&#58; a clinicoprognostic study of 126 cases"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
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ISSN: 00017310
Original language: Spanish
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