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3</a>&#41;&#46; The staging study revealed enlarged retroperitoneal and perivascular lymph nodes&#44; adequate differentiation of the 3 hematopoietic cell lines&#44; and an absence of neoplastic infiltration in the bone-marrow biopsy specimen&#46; These findings led to a final diagnosis of well-differentiated&#44; low-grade&#44; stage IIIA follicular B-cell lymphoma&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The findings of a new histologic examination of a different skin lesion&#44; performed after the lesions had increased in number&#44; were similar to those of the first biopsy&#59; <span class="elsevierStyleItalic">IGH</span> gene rearrangement was not detected&#44; however&#44; due to insufficient genetic material&#46; The patient began treatment with monthly cycles of fludarabine &#40;40<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; and cyclophosphamide &#40;250<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; for 3 days each month followed by a single dose of rituximab &#40;375<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#59; she was administered 4 cycles&#46; She was then administered 4 cycles of a single weekly dose of rituximab &#40;375<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46; Six months after completing the treatment regimen&#44; the patient had achieved complete remission of the malignancy and the skin lesions had regressed&#44; leaving depressed&#44; hyperpigmented scars &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; After 2 years of follow-up&#44; no new skin lesions have appeared and there is no evidence of hematologic recurrence&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Adult-onset JXG was first described in 1963&#44; since which time 125 cases have been reported&#44; most consisting of solitary lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Nevertheless&#44; in the literature we have identified 21 cases with more than 10 disseminated lesions&#44; with histologic findings similar to those seen in children with JXG&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;6</span></a> Seven of the reviewed cases of adult-onset JXG were associated with hematologic malignancies<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; most frequently leukemias &#40;3 cases&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> followed by lymphomas &#40;2 cases&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5</span></a> monoclonal gammopathy &#40;1 case&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and essential thrombocytosis &#40;1 case&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> We did not find any cases of JXG associated with follicular lymphoma&#46; The present case is therefore the first report of this association&#46; In all cases in which JXG was associated with a blood dyscrasia&#44; the patients presented multiple lesions with purely cutaneous involvement&#44; with the exception of 1 case with periocular involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> JXG developed before&#44; concomitantly with&#44; or after diagnosis of the hematologic malignancy&#44; with intervals that ranged from 5 months to 9 years&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The response of the JXG and the tumor to treatment targeting the hematologic neoplasm was variable&#46; Remission of the tumor and regression of the skin lesions occurred in only 2 cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Some studies have reported that children who have JXG and neurofibromatosis have an increased risk of developing leukemia&#44; but doubts about this association have subsequently been raised&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Two cases have been reported in children of JXG with disseminated cutaneous involvement associated with myeloproliferative diseases&#46; One report described a 3-year-old boy who was diagnosed with JXG and 6 months later developed B-cell acute lymphoblastic leukemia &#40;B-ALL&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The patient failed to achieve remission with chemotherapy&#44; although the skin lesions did flatten slightly&#46; The other case was a newborn with JXG and hemophagocytic lymphohistiocytosis who developed chronic juvenile myelomonocytic leukemia&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Castro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> described the cases of 3 children between the ages of 8 and 13 years who presented JXG lesions in unusual locations&#8212;lymph nodes&#44; bones&#44; and lungs&#8212;in association with ALL&#46; The intervals between the appearance of JXG and the onset of ALL ranged from 1 to 12 years&#46; However&#44; given the higher incidence of this disease in children&#44; its self-resolving course&#44; and reports of atypical forms of presentation&#44; we believe that the association between JXG and blood neoplasms is weaker in children&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding the etiology and pathogenesis&#44; it has been speculated that histiocytoses develop as a result of the proliferation of a common CD34<span class="elsevierStyleSup">&#43;</span> precursor cell in the bone marrow&#46; The abnormal multiplication of these cells is caused by the action of various stimuli&#44; including cytokines or gamma globulins produced by an underlying malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Moreover&#44; it has been suggested that some cases of Langerhans cell histiocytosis associated with myeloproliferative or lymphoproliferative diseases may have a common origin in a hematopoietic precursor cell capable of dedifferentiating both into tumor cells&#44; which leads to the neoplasm&#44; and into cells of monocyte-dendritic lineage&#44; which leads to histiocytosis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> A recent study described a case of JXG with visceral involvement &#40;liver and spleen&#41; in a child aged 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Three months after the patient was diagnosed with T-ALL&#44; clonal biallelic rearrangement of <span class="elsevierStyleItalic">TCR&#947;</span> in blasts and histiocytes was detected&#46; In our patient&#44; we were unable to establish a clonal relationship between the lymphoproliferative cells and the histiocytes that formed part of the skin lesions because the skin biopsy specimen contained insufficient genetic material&#46; In the literature&#44; we found no other cases of JXG with clonal rearrangement among either the hematologic tumor cell population or the histiocytosis&#46; It would therefore be interesting&#44; in future studies&#44; to demonstrate this association in patients with both diseases&#46; This research could be extended to other cases of blood dyscrasias associated with various types of non-Langerhans cell histiocytosis&#44; such as xanthoma disseminatum and necrobiotic xanthogranuloma&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">No treatment regimen has been shown to cure disseminated adult-onset JXG&#46; Patients with JXG and neoplastic disease whose skin lesions improved did so in response to antineoplastic therapy&#46; Our patient received chemotherapy with fludarabine and cyclophosphamide in combination with rituximab &#40;an anti-CD20 monoclonal antibody that inhibits CD20<span class="elsevierStyleSup">&#43;</span> lymphocytes&#41;&#46; The cytostatic treatment induced apoptosis in the neoplastic cells&#44; thereby inhibiting the production of various cytokines and other mediators that might otherwise have participated in histiocytic proliferation&#46; Various mechanisms by which rituximab may inhibit lymphocytes have been proposed&#44; including modulation through the macrophage-histiocyte system&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> which could have contributed to the resolution of JXG in our patient&#46; Our review of the literature has revealed no previous reports of disseminated JXG being treated with rituximab&#44; although there has been a description of complete resolution of a necrobiotic xanthogranuloma associated with lymphocytic lymphoma in a patient who followed the same treatment regimen as our patient&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">This is the first report in an adult of disseminated JXG associated with follicular lymphoma with an excellent response to cytostatic treatment and rituximab&#46; This result supports the hypothesis that JXG is associated with hematologic malignancies&#46; Not enough cases have been reported for this entity to be considered a true paraneoplastic syndrome&#46; Nevertheless&#44; it is advisable to follow up these patients using general physical examination and additional tests to screen for tumors&#8212;especially hematologic ones&#8212;in those patients who have numerous lesions that have appeared progressively&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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        0 => array:2 [
          "identificador" => "xres97880"
          "titulo" => "Abstract"
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        1 => array:2 [
          "identificador" => "xpalclavsec85037"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres97881"
          "titulo" => "Resumen"
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        3 => array:2 [
          "identificador" => "xpalclavsec85036"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case Description"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conclusion"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflicts of Interest"
        ]
        9 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-07-17"
    "fechaAceptado" => "2012-02-10"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec85037"
          "palabras" => array:3 [
            0 => "Juvenile xanthogranuloma"
            1 => "Lymphoma follicular"
            2 => "Non-Langerhans-cell histiocytosis"
          ]
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      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec85036"
          "palabras" => array:4 [
            0 => "Xantogranuloma juvenil"
            1 => "Linfoma folicular"
            2 => "Histiocitosis de c&#233;lulas no"
            3 => "Langerhans"
          ]
        ]
      ]
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    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Juvenile xanthogranuloma is a non-Langerhans cell histiocytosis that typically affects children&#44; but several cases have been reported in adults&#44; some in connection with hematologic malignancies&#46; We present the case of a 61-year-old woman with multiple xanthogranulomas who developed a follicular lymphoma after 4 years of follow-up&#46; After 6 months of treatment with chemotherapy and rituximab&#44; the cutaneous lesions disappeared and the patient achieved remission from lymphoma&#46; We highlight this case because xanthogranuloma is a rare disorder that is difficult to diagnose in adults and also because this is the first report of an association between xanthogranuloma and follicular lymphoma&#46; Excellent response was achieved with chemotherapy and rituximab&#46; Finally&#44; given the possible association between xanthogranulomas and hematologic diseases&#44; these lesions may be a cutaneous manifestation of an occult malignancy&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El xantogranuloma juvenil &#40;XGJ&#41; es una histiocitosis de c&#233;lulas no Langerhans que acontece en la edad infantil&#44; sin embargo&#44; se han descrito varios casos en el adulto&#44; algunos de ellos en relaci&#243;n con hemopat&#237;as malignas&#46; Presentamos el caso de una mujer de 61 a&#241;os de edad con lesiones diseminadas de XGJ que a los 4 a&#241;os de seguimiento desarroll&#243; un linfoma de tipo folicular&#46; Tras 6 meses de tratamiento con quimioterapia y rituximab se consigui&#243; remisi&#243;n del linfoma y la involuci&#243;n de las lesiones cut&#225;neas&#46; Destacamos este caso por tratarse de una entidad poco frecuente y de dif&#237;cil diagn&#243;stico en el adulto&#44; as&#237; como por ser el primer caso asociado con linfoma folicular y que ha presentado una excelente respuesta con quimioterapia y rituximab&#46; Adem&#225;s&#44; dada su posible asociaci&#243;n con enfermedades hematol&#243;gicas&#44; el XGJ podr&#237;a representar una manifestaci&#243;n de una neoplasia oculta&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Narv&#225;ez-Moreno B&#44; et al&#46; Xantogranuloma juvenil diseminado del adulto asociado a lin-foma folicular&#44; respuesta completa a quimioterapia y rituximab&#46; Revisi&#243;n de la literatura&#46; Actas Dermosifiliogr&#46; 2013&#59;104&#58;242&#8211;6</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#44; Multiple yellowish-brown papular lesions on the patient&#39;s trunk&#46; B&#44; Detail of the lesions&#46; C&#44; Hyperpigmented scars after completion of the treatment&#46;</p>"
        ]
      ]
      1 => array:7 [
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        "etiqueta" => "Figure 2"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diffuse infiltrate located mainly in the mid dermis that dissects collagen bundles and that forms aggregates in the deep dermis&#44; shown at high magnification &#40;hematoxylin-eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>40&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1565
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            "Tamanyo" => 562382
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A&#44; Infiltrate composed of cells with abundant cytoplasm and a histiocytic appearance&#44; some multinucleated giant cells&#44; lymphocytes with no atypia&#44; and a few eosinophils &#40;hematoxylin-eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>100&#41;&#46; B&#44; Immunohistochemistry showing a negative result for CD1a &#40;original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46; C&#44; Immunohistochemistry showing granular positivity for CD68 in the cellular cytoplasm &#40;original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46; D&#44; Histology of inguinal lymph node showing a lymphoid proliferation of centrocytes &#40;small cleaved cells&#41; &#40;original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>100&#41;&#46;</p>"
        ]
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      3 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Adapted from Shoo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Abbreviations&#58; B-ALL&#44; B-cell acute lymphoblastic leukemia&#59; B-CLL&#44; B-cell chronic lymphocytic leukemia&#59; F&#44; female&#59; JXG&#44; juvenile xanthogranuloma&#59; M&#44; male&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Bibliographic Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Age&#44; y&#47;Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical Presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Hematologic Disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Temporal Relationship Between Hematologic Malignancy and JXG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Response to Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Case Presented&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#47;F&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">Multiple&#44; disseminated&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">Follicular lymphoma&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 y later&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">Fludarabine&#44; cyclophosphamide&#44; rituximab&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">Both&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Biswas et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#47;M&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">Ocular&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">B-CLL&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 y before&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">None&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">JXG&#44; spontaneous resolution after 2 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Shoo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#47;M&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">Multiple&#44; disseminated&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">B-ALL&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">Simultaneous&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">No data available&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">No data available&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Shoo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#47;F&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">Multiple&#44; disseminated&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">Large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 y later&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">No data available&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">JXG&#44; no response&#59; lymphoma&#44; remission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Larson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#47;M&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">Multiple&#44; disseminated&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">CLL&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 mo before&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">No data available&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">Both&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Larson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#47;M&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">Multiple&#44; disseminated&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">Monoclonal gammopathy&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 mo before&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">No data available&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">No data available&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Pino et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#47;M&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">Multiple&#44; disseminated&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">Essential thrombocytosis&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 y later&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">Hydroxyurea&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">Both&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Chiou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#47;F&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">Multiple&#44; disseminated&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">Adult T-cell leukemia&#47;lymphoma&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 y later&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">Prednisone&#44; chlorambucil&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">No response&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab183317.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cases of Adult-Onset Juvenile Xanthogranuloma Associated with Hematologic Malignancy&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:15 [
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                            1 => "P&#46; Eguino"
                            2 => "I&#46; Tr&#233;bol"
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                            5 => "J&#46;L&#46; D&#237;az-P&#233;rez"
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                  "host" => array:1 [
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                            "web" => "Medline"
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            1 => array:3 [
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                            1 => "B&#46; Naskar"
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                            1 => "B&#46; Hamid"
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            3 => array:3 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            1 => "K&#46; Shinkai"
                            2 => "T&#46;H&#46; McCalmont"
                            3 => "L&#46;P&#46; Fox"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2008.03.046"
                      "Revista" => array:6 [
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                            "web" => "Medline"
                          ]
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              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Disseminated xanthogranulomas associated with adult T-cell leukaemia&#47;lymphoma&#58; a case report and review the association of haematologic malignancies"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46;C&#46; Chiou"
                            1 => "P&#46;N&#46; Wang"
                            2 => "L&#46;C&#46; Yang"
                            3 => "T&#46;T&#46; Kuo"
                            4 => "H&#46;S&#46; Hong"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1468-3083.2006.02013.x"
                      "Revista" => array:6 [
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                            "web" => "Medline"
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                        ]
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              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
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                            0 => "M&#46;J&#46; Larson"
                            1 => "C&#46; Bandel"
                            2 => "P&#46;J&#46; Eichhorn"
                            3 => "P&#46;D Cruz Jr&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2003.08.019"
                      "Revista" => array:6 [
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                        ]
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                ]
              ]
            ]
            6 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multiple xanthogranulomas in an adult&#44; associated with essential thrombocytosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "G&#46;M&#46; Pino"
                            1 => "F&#46;J&#46; Miquel"
                            2 => "M&#46; Velasco"
                            3 => "J&#46;J&#46; Vilata"
                            4 => "A&#46; Aliaga"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
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Case Report
Disseminated Juvenile Xanthogranuloma Associated With Follicular Lymphoma in an Adult: Successful Treatment With Chemotherapy and Rituximab. A Review of the Literature
Xantogranuloma juvenil diseminado del adulto asociado a linfoma folicular, respuesta completa a quimioterapia y rituximab. Revisión de la literatura
B. Narváez-Morenoa,
Corresponding author
basnarmor@hotmail.com

Corresponding author.
, Á. Pulpillo-Ruiza, T. De Zulueta-Doradob, J. Conejo-Mira
a Servicio de Gestión Clínica Dermatología, Hospitales Universitarios Virgen del Rocío, Seville, Spain
b Servicio de Anatomía Patológica, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Juvenile xanthogranuloma &#40;JXG&#41; is a non-Langerhans cell histiocytosis that typically affects young children&#46; It is characterized by multiple yellowish-brown papulonodular lesions that resolve spontaneously&#46; Histologically&#44; these lesions are characterized by histiocytes and Touton-type multinucleated giant cells&#46; Most of the few cases of JXG that have been reported in adults consist of solitary lesions that do not regress spontaneously&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> JXG has gained interest because of its possible association with oncohematologic diseases&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 61-year-old woman &#40;occasional smoker&#41; diagnosed 30 years earlier with latent tuberculosis&#46; She had undergone curettage of the uterus to treat a uterine fibroid and had required a blood transfusion&#46; In 2004&#44; yellowish-brown papular lesions 3 to 5<span class="elsevierStyleHsp" style=""></span>mm in diameter began to appear on the patient&#39;s trunk&#46; The lesions increased in number&#44; gradually spreading across the abdomen and the proximal areas of the limbs &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; A and B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Histologic examination of one of the lesions revealed a diffuse infiltrate located mainly in the mid dermis that dissected collagen bundles and formed aggregates in the deep dermis&#46; The infiltrate was composed primarily of cells with abundant cytoplasm and a histiocytic appearance&#44; as well as multinucleated giant cells&#44; some of which were Touton-type&#44; mixed with occasional lymphocytes with no atypia and a few eosinophils &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46; Immunohistochemistry was positive for cells of monocyte-macrophage lineage &#40;CD68&#41; and negative for Langerhans cells &#40;s-100 protein and CD1a&#41;&#46; A diagnosis of adult-onset JXG was established&#46; The patient began outpatient follow-up care and continued to develop clinically similar lesions&#46; After 4 years of follow-up&#44; the patient was found to have an enlarged left inguinal lymph node that was growing rapidly&#44; with no other associated symptoms&#46; The lymph node was excised and histology revealed a nodular lymphoproliferative process consisting of centrocytes with a germinal center phenotype &#40;immunohistochemistry was positive for CD20&#44; CD23&#44; and CD10 in follicular areas&#44; with diffuse expression of Bcl-2 and selective expression of Bcl-6 in the follicles&#41;&#44; which indicated clonal <span class="elsevierStyleItalic">IGH</span> gene rearrangement &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The staging study revealed enlarged retroperitoneal and perivascular lymph nodes&#44; adequate differentiation of the 3 hematopoietic cell lines&#44; and an absence of neoplastic infiltration in the bone-marrow biopsy specimen&#46; These findings led to a final diagnosis of well-differentiated&#44; low-grade&#44; stage IIIA follicular B-cell lymphoma&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The findings of a new histologic examination of a different skin lesion&#44; performed after the lesions had increased in number&#44; were similar to those of the first biopsy&#59; <span class="elsevierStyleItalic">IGH</span> gene rearrangement was not detected&#44; however&#44; due to insufficient genetic material&#46; The patient began treatment with monthly cycles of fludarabine &#40;40<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; and cyclophosphamide &#40;250<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; for 3 days each month followed by a single dose of rituximab &#40;375<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#59; she was administered 4 cycles&#46; She was then administered 4 cycles of a single weekly dose of rituximab &#40;375<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46; Six months after completing the treatment regimen&#44; the patient had achieved complete remission of the malignancy and the skin lesions had regressed&#44; leaving depressed&#44; hyperpigmented scars &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; After 2 years of follow-up&#44; no new skin lesions have appeared and there is no evidence of hematologic recurrence&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Adult-onset JXG was first described in 1963&#44; since which time 125 cases have been reported&#44; most consisting of solitary lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Nevertheless&#44; in the literature we have identified 21 cases with more than 10 disseminated lesions&#44; with histologic findings similar to those seen in children with JXG&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;6</span></a> Seven of the reviewed cases of adult-onset JXG were associated with hematologic malignancies<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; most frequently leukemias &#40;3 cases&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> followed by lymphomas &#40;2 cases&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5</span></a> monoclonal gammopathy &#40;1 case&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and essential thrombocytosis &#40;1 case&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> We did not find any cases of JXG associated with follicular lymphoma&#46; The present case is therefore the first report of this association&#46; In all cases in which JXG was associated with a blood dyscrasia&#44; the patients presented multiple lesions with purely cutaneous involvement&#44; with the exception of 1 case with periocular involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> JXG developed before&#44; concomitantly with&#44; or after diagnosis of the hematologic malignancy&#44; with intervals that ranged from 5 months to 9 years&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The response of the JXG and the tumor to treatment targeting the hematologic neoplasm was variable&#46; Remission of the tumor and regression of the skin lesions occurred in only 2 cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Some studies have reported that children who have JXG and neurofibromatosis have an increased risk of developing leukemia&#44; but doubts about this association have subsequently been raised&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Two cases have been reported in children of JXG with disseminated cutaneous involvement associated with myeloproliferative diseases&#46; One report described a 3-year-old boy who was diagnosed with JXG and 6 months later developed B-cell acute lymphoblastic leukemia &#40;B-ALL&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The patient failed to achieve remission with chemotherapy&#44; although the skin lesions did flatten slightly&#46; The other case was a newborn with JXG and hemophagocytic lymphohistiocytosis who developed chronic juvenile myelomonocytic leukemia&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Castro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> described the cases of 3 children between the ages of 8 and 13 years who presented JXG lesions in unusual locations&#8212;lymph nodes&#44; bones&#44; and lungs&#8212;in association with ALL&#46; The intervals between the appearance of JXG and the onset of ALL ranged from 1 to 12 years&#46; However&#44; given the higher incidence of this disease in children&#44; its self-resolving course&#44; and reports of atypical forms of presentation&#44; we believe that the association between JXG and blood neoplasms is weaker in children&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding the etiology and pathogenesis&#44; it has been speculated that histiocytoses develop as a result of the proliferation of a common CD34<span class="elsevierStyleSup">&#43;</span> precursor cell in the bone marrow&#46; The abnormal multiplication of these cells is caused by the action of various stimuli&#44; including cytokines or gamma globulins produced by an underlying malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Moreover&#44; it has been suggested that some cases of Langerhans cell histiocytosis associated with myeloproliferative or lymphoproliferative diseases may have a common origin in a hematopoietic precursor cell capable of dedifferentiating both into tumor cells&#44; which leads to the neoplasm&#44; and into cells of monocyte-dendritic lineage&#44; which leads to histiocytosis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> A recent study described a case of JXG with visceral involvement &#40;liver and spleen&#41; in a child aged 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Three months after the patient was diagnosed with T-ALL&#44; clonal biallelic rearrangement of <span class="elsevierStyleItalic">TCR&#947;</span> in blasts and histiocytes was detected&#46; In our patient&#44; we were unable to establish a clonal relationship between the lymphoproliferative cells and the histiocytes that formed part of the skin lesions because the skin biopsy specimen contained insufficient genetic material&#46; In the literature&#44; we found no other cases of JXG with clonal rearrangement among either the hematologic tumor cell population or the histiocytosis&#46; It would therefore be interesting&#44; in future studies&#44; to demonstrate this association in patients with both diseases&#46; This research could be extended to other cases of blood dyscrasias associated with various types of non-Langerhans cell histiocytosis&#44; such as xanthoma disseminatum and necrobiotic xanthogranuloma&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">No treatment regimen has been shown to cure disseminated adult-onset JXG&#46; Patients with JXG and neoplastic disease whose skin lesions improved did so in response to antineoplastic therapy&#46; Our patient received chemotherapy with fludarabine and cyclophosphamide in combination with rituximab &#40;an anti-CD20 monoclonal antibody that inhibits CD20<span class="elsevierStyleSup">&#43;</span> lymphocytes&#41;&#46; The cytostatic treatment induced apoptosis in the neoplastic cells&#44; thereby inhibiting the production of various cytokines and other mediators that might otherwise have participated in histiocytic proliferation&#46; Various mechanisms by which rituximab may inhibit lymphocytes have been proposed&#44; including modulation through the macrophage-histiocyte system&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> which could have contributed to the resolution of JXG in our patient&#46; Our review of the literature has revealed no previous reports of disseminated JXG being treated with rituximab&#44; although there has been a description of complete resolution of a necrobiotic xanthogranuloma associated with lymphocytic lymphoma in a patient who followed the same treatment regimen as our patient&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">This is the first report in an adult of disseminated JXG associated with follicular lymphoma with an excellent response to cytostatic treatment and rituximab&#46; This result supports the hypothesis that JXG is associated with hematologic malignancies&#46; Not enough cases have been reported for this entity to be considered a true paraneoplastic syndrome&#46; Nevertheless&#44; it is advisable to follow up these patients using general physical examination and additional tests to screen for tumors&#8212;especially hematologic ones&#8212;in those patients who have numerous lesions that have appeared progressively&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Juvenile xanthogranuloma is a non-Langerhans cell histiocytosis that typically affects children&#44; but several cases have been reported in adults&#44; some in connection with hematologic malignancies&#46; We present the case of a 61-year-old woman with multiple xanthogranulomas who developed a follicular lymphoma after 4 years of follow-up&#46; After 6 months of treatment with chemotherapy and rituximab&#44; the cutaneous lesions disappeared and the patient achieved remission from lymphoma&#46; We highlight this case because xanthogranuloma is a rare disorder that is difficult to diagnose in adults and also because this is the first report of an association between xanthogranuloma and follicular lymphoma&#46; Excellent response was achieved with chemotherapy and rituximab&#46; Finally&#44; given the possible association between xanthogranulomas and hematologic diseases&#44; these lesions may be a cutaneous manifestation of an occult malignancy&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El xantogranuloma juvenil &#40;XGJ&#41; es una histiocitosis de c&#233;lulas no Langerhans que acontece en la edad infantil&#44; sin embargo&#44; se han descrito varios casos en el adulto&#44; algunos de ellos en relaci&#243;n con hemopat&#237;as malignas&#46; Presentamos el caso de una mujer de 61 a&#241;os de edad con lesiones diseminadas de XGJ que a los 4 a&#241;os de seguimiento desarroll&#243; un linfoma de tipo folicular&#46; Tras 6 meses de tratamiento con quimioterapia y rituximab se consigui&#243; remisi&#243;n del linfoma y la involuci&#243;n de las lesiones cut&#225;neas&#46; Destacamos este caso por tratarse de una entidad poco frecuente y de dif&#237;cil diagn&#243;stico en el adulto&#44; as&#237; como por ser el primer caso asociado con linfoma folicular y que ha presentado una excelente respuesta con quimioterapia y rituximab&#46; Adem&#225;s&#44; dada su posible asociaci&#243;n con enfermedades hematol&#243;gicas&#44; el XGJ podr&#237;a representar una manifestaci&#243;n de una neoplasia oculta&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diffuse infiltrate located mainly in the mid dermis that dissects collagen bundles and that forms aggregates in the deep dermis&#44; shown at high magnification &#40;hematoxylin-eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>40&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1565
            "Ancho" => 1655
            "Tamanyo" => 562382
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A&#44; Infiltrate composed of cells with abundant cytoplasm and a histiocytic appearance&#44; some multinucleated giant cells&#44; lymphocytes with no atypia&#44; and a few eosinophils &#40;hematoxylin-eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>100&#41;&#46; B&#44; Immunohistochemistry showing a negative result for CD1a &#40;original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46; C&#44; Immunohistochemistry showing granular positivity for CD68 in the cellular cytoplasm &#40;original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46; D&#44; Histology of inguinal lymph node showing a lymphoid proliferation of centrocytes &#40;small cleaved cells&#41; &#40;original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>100&#41;&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Adapted from Shoo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Abbreviations&#58; B-ALL&#44; B-cell acute lymphoblastic leukemia&#59; B-CLL&#44; B-cell chronic lymphocytic leukemia&#59; F&#44; female&#59; JXG&#44; juvenile xanthogranuloma&#59; M&#44; male&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Bibliographic Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Age&#44; y&#47;Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical Presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Hematologic Disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Temporal Relationship Between Hematologic Malignancy and JXG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Response to Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Case Presented&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#47;F&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">Multiple&#44; disseminated&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">Follicular lymphoma&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 y later&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">Fludarabine&#44; cyclophosphamide&#44; rituximab&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">Both&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Biswas et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#47;M&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">Ocular&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">B-CLL&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 y before&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">None&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">JXG&#44; spontaneous resolution after 2 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Shoo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#47;M&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">Multiple&#44; disseminated&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">B-ALL&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">Simultaneous&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">No data available&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">No data available&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Shoo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#47;F&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">Multiple&#44; disseminated&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">Large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 y later&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">No data available&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">JXG&#44; no response&#59; lymphoma&#44; remission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Larson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#47;M&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">Multiple&#44; disseminated&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">CLL&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 mo before&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">No data available&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">Both&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Larson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#47;M&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">Multiple&#44; disseminated&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">Monoclonal gammopathy&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 mo before&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">No data available&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">No data available&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Pino et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#47;M&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">Multiple&#44; disseminated&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">Essential thrombocytosis&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 y later&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">Hydroxyurea&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">Both&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Chiou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#47;F&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">Multiple&#44; disseminated&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">Adult T-cell leukemia&#47;lymphoma&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 y later&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">Prednisone&#44; chlorambucil&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">No response&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?