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Cost Analysis of Sentinel Lymph Node Biopsy in Melanoma
Evaluación del coste económico de la técnica de la biopsia selectiva del ganglio centinela en melanoma
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Martínez-Menchón, P. Sánchez-Pedreño, J. Martínez-Escribano, R. Corbalán-Vélez, E. Martínez-Barba" "autores" => array:5 [ 0 => array:4 [ "nombre" => "T." "apellidos" => "Martínez-Menchón" "email" => array:1 [ 0 => "teresammenchon@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Sánchez-Pedreño" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Martínez-Escribano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "R." 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Tel.: +657742724." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación del coste económico de la técnica de la biopsia selectiva del ganglio centinela en melanoma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1587 "Ancho" => 3003 "Tamanyo" => 226661 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagram illustrating how the sentinel node sections were obtained and processed. A, Transhilar bivalving. B, Parallel processing (breadloafing).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The optimal node staging approach in melanoma is based on sentinel lymph node biopsy (SLNB), which serves as a guide for selective lymphadenectomy performed in node-positive cases.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Guidelines for referring patients for SLNB are constantly changing. In general, biopsy is recommended in cases of primary melanoma without evidence of regional or distant metastasis when the risk of node metastasis is at least 10%, which is to say clinical stages IB and IIA, B, and C according to the 7th edition of the staging manual of the American Joint Committee on Cancer. Selection criteria have not yet been standardized for cases with a Breslow thickness of less than 0.75<span class="elsevierStyleHsp" style=""></span>mm, but defining a treatment approach for this subgroup of patients will become crucial given that they now account for 60% to 70% of melanomas diagnosed in large hospitals.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,3</span></a> This group has grown more rapidly than others in recent years.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A lower threshold for significant node metastasis has not yet been established; thus, a finding of a single isolated melanoma cell in the sentinel node would be sufficient grounds for a positive classification and, therefore, would lead to a change in therapeutic approach. Given that the most recent melanoma guidelines of the American Joint Committee on Cancer<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> stipulate that identifying a single melanoma cell should be the goal, histologic processing of the biopsied material should be as exhaustive as possible. As processing is inevitably incomplete, however, finding single cells will be largely a matter of chance.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Clear standardization of an approach to histologic processing of the sentinel node is also lacking, though transhilar bivalving and examination of parallel slices (breadloafing) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) are techniques that have received attention.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5,6</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Our principal aim was to assess the cost of SLNB in our practice setting, a referral hospital for the Spanish region of Murcia, given that this procedure has become the standard of care for patients with melanoma and is also necessary whenever patients are to be enrolled in clinical trials. Few cost studies have been done in Spain, however, and our view is that the economic impact of SLNB has been underestimated. A prospective observational study was therefore designed to estimate SLNB-related costs in our hospital.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Information for 100 patients undergoing SLNB in the period from 2007 to 2010 was recorded in a database. A standardized transhilar bivalving technique was used in all cases. The inclusion criteria were as follows: primary cutaneous melanoma with a Breslow thickness of at least 1<span class="elsevierStyleHsp" style=""></span>mm or 0.75<span class="elsevierStyleHsp" style=""></span>mm if there were concurrent signs associated with greater likelihood of node positivity (i.e., ulceration, regression, age under 40 years, or lymph vessel invasion). Melanomas in pediatric patients were excluded because the natural history of these tumors differs in adults and children.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study was carried out in the dermatology department of Hospital Clínico Universitario Virgen de la Arrixaca, which is the referral hospital for SLNB. The hospital's catchment area has approximately 560 000 inhabitants.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">SLNB Technique</span><p id="par0035" class="elsevierStylePara elsevierViewall">We injected a technetium-99 radiolabeled tracer (Lymphoscint, Amersham, Saluggia, Italy) with colloid particles 50 to 100<span class="elsevierStyleHsp" style=""></span>nm in diameter. The amount of solution was 1<span class="elsevierStyleHsp" style=""></span>mL, distributed in 4 intradermal injections of 250<span class="elsevierStyleHsp" style=""></span>μCi, each containing 1<span class="elsevierStyleHsp" style=""></span>μCi (37<span class="elsevierStyleHsp" style=""></span>MBq) of the tracer. The injections were made around the lesion (or around the scar in the case of previously excised lesions closed by direct suture without flaps or graft reconstructions). A tracer uptake time of 2 to 4<span class="elsevierStyleHsp" style=""></span>hours was allowed before the procedure. After the gamma-camera guided injections, sequential and dynamic images were recorded every 10<span class="elsevierStyleHsp" style=""></span>seconds for 5<span class="elsevierStyleHsp" style=""></span>minutes. Immediately afterwards, a static image of a single projection was recorded for 180<span class="elsevierStyleHsp" style=""></span>seconds (matrix, 256<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>256 pixels). We considered the gamma camera to be correctly placed if 1 or more draining nodes could be identified; the first such nodes that appeared were considered sentinel nodes and their locations were marked. If nodes were not found, another acquisition was attempted an hour later; yet another attempt 2<span class="elsevierStyleHsp" style=""></span>hours later might also be made. If a sentinel or other draining mode was adequately located it was biopsied in the operating room, with the aid of images from the preoperative lymphoscintigram and guidance from a handheld gamma probe. To minimize damage to the node, the biopsy was harvested with Babcock forceps, and diathermy for hemostasis was used cautiously.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Histologic Processing</span><p id="par0040" class="elsevierStylePara elsevierViewall">The processing protocol included transhilar bivalving of the node and multiple-level parallel sectioning. The sentinel nodes were fixed in formalin for 24<span class="elsevierStyleHsp" style=""></span>hours and then embedded in paraffin. Five serial sections of 5<span class="elsevierStyleHsp" style=""></span>μ each were stained with hematoxylin and eosin (H&E) (2 slices) for histology; immunohistostaining with antibodies for S100, HMB-45, and Melan-A completed the processing of these zero-level studies. Then, 250<span class="elsevierStyleHsp" style=""></span>μ was sliced into 5 additional sections for histologic and immunohistochemical staining of another level. This process of step-sectioning the material was repeated at intervals of 250<span class="elsevierStyleHsp" style=""></span>μ. Each node was approximately 4<span class="elsevierStyleHsp" style=""></span>mm in diameter so on average, 9 levels could be studied once the bivalved node had been placed in cassettes for paraffin embedding. As described above, the sections sliced from each level were processed with H&E, anti-Melan-A, anti-S100, and anti-HMB-45 staining to give an average of 45 processed sections for the pathologist to evaluate in total (in levels corresponding to 0, 250, 500, 750, 1000, 1250, 1500, 1750, and 2000 μ) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Fee and Price Schedule</span><p id="par0045" class="elsevierStylePara elsevierViewall">Our cost study was based on unit prices found in the fee and price schedule published in the regional government's official gazette (<span class="elsevierStyleItalic">Boletín Oficial de la Región de Murcia</span>, February 2013). Our hospital's accounting and analysis department did not make available their data on actual spending. The published prices are used by the hospital to invoice third parties and are approximate indications of real costs. Both direct and indirect costs were included, such that staffing and maintenance of the facilities were reflected. There is no unit price specified for whole the set of services related to SLNB in the diagnosis of melanoma; we therefore added up the costs for each of the component procedures performed in the process.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">Of a total of 100 patients diagnosed with melanoma who underwent SLNB from 2007 to 2010, all inclusion criteria were met by 99 patients, whose data entered the analysis.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The mean Breslow thickness was 2.02<span class="elsevierStyleHsp" style=""></span>mm (median, 1<span class="elsevierStyleHsp" style=""></span>mm); 20% of the cases were node-positive. A mean (SD) of 1.96 (1.46) nodes (95% CI, 0.50–3.42 nodes) were excised per patient (median, 1); for cost estimates, the mean was rounded up to 2. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows descriptive data for the series. The Breslow thickness was less than 1<span class="elsevierStyleHsp" style=""></span>mm in 44 (44%) patients; 1 of these patients (2.2% of the 44) had a positive node.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The hospital's fees for the various procedures required for SLNB are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Accordingly, the total cost of biopsying an axillary node was €3717.21; the cost was €4701.93 for an inguinal node. If more than 1 drainage pathway was identified, costs increased.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Histopathologic processing of multiple-level sections amounted to approximately €2884.68 in this hospital series (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Given that our hospital biopsied 2 nodes per case on average, the price of histopathologic processing came to €5769.36 per case. The total cost of SLNB therefore ranged from €9486.57 to €10 471.29.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">This study found that SLNB-related costs ranged between €9486.57 and €10 471.29 in this prospectively enrolled series of 99 patients treated in our referral hospital in the Spanish region of Murcia.</p><p id="par0080" class="elsevierStylePara elsevierViewall">As a basis for comparison with other procedures performed in the hospital, we mention that the unit prices for kidney and liver transplants are €27 327.71 and €92 581.04, respectively, indicating that the cost of SLNB is by no means negligible.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Our hospital has been performing SLNB for approximately 20 years. The multidisciplinary team responsible for the procedure is comprised of members of the dermatology, general surgery, nuclear medicine, and pathology departments. An operating room for major outpatient surgery is used, and patients are usually hospitalized for 1 day. As no immediate postoperative complications that prolonged hospitalization developed in this series, all patients were discharged the next day.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The costs we calculated are consistent with the range of $10 000 to $15 000 (€7620 to €11 431) reported earlier by a US hospital.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Only one other study in Spain has analyzed the costs of the various steps in the diagnosis and treatment of cutaneous melanoma.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> The authors of that study estimated the general costs of SLNB to be €682.24 (with 1 day of hospitalization and re-excision of the melanoma scar with margins of 2<span class="elsevierStyleHsp" style=""></span>cm), but they did not describe the process they used for sentinel-node histology.</p><p id="par0100" class="elsevierStylePara elsevierViewall">A cost-effectiveness study in Australia by Morton et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> estimated that their procedure (without study of safety margins) cost €1902.45. We point out that the approach to histologic processing was not detailed in that study either, even though this component of SLNB is responsible for higher costs.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Our results show that histologic processing accounts for a large portion of the cost of SLNB. Many processing approaches have been used, and their ability to detect positive nodes depends on how exhaustively the material is assessed. Examination of parallel slices (breadloafing) must be distinguished from transhilar bivalving approaches (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). The European Organisation for Research and Treatment of Cancer currently recommends that the sentinel node be examined with the histopathologic method described by Cook et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> This approach relies on transhilar bivalving and assessment of material in step sections of 50<span class="elsevierStyleHsp" style=""></span>μ. At each step, or processing level, 4 slices are cut and prepared with H&E, anti-S100, anti-HMB-45, and Pan Melanoma Plus stains. Some material is left unstained in case the node must be reassessed. This protocol examines about 700<span class="elsevierStyleHsp" style=""></span>to 800<span class="elsevierStyleHsp" style=""></span>μ, not the entire node. In fact, the recommended method is neither rapid nor easy to standardize, and it generates costs that many hospitals are unable to absorb. Findings from a study by Bastistatou et al.,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> based on a telephone survey of dermatopathologists who were members of the European Society of Pathology, illustrated these problems: only 48% of the respondents used transhilar bivalving and only 42% used a method of parallel slicing. The respondents examined from 1 to 20 steps. The most complete processing approach involves multiple slices for histology and the use of immunohistochemical stains that add considerably to the overall expense. Our current approach to assessing the sentinel node follows the guidelines for treating melanoma in the region of Murcia<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a>; very similar guidelines are used in Valencia.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">How long the pathologist takes to assess all the slices should also be taken into consideration. We estimated assessment took 2<span class="elsevierStyleHsp" style=""></span>minutes per slice on average; thus if 36<span class="elsevierStyleHsp" style=""></span>to 45 are to be assessed, a pathologist will spend at least 72<span class="elsevierStyleHsp" style=""></span>minutes on a single node. As a case involves 2<span class="elsevierStyleHsp" style=""></span>nodes on average, 144<span class="elsevierStyleHsp" style=""></span>minutes of a pathologist's time will be required for each patient undergoing SLNB.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The use of this technique should be as restricted as possible. In a case with a low Breslow index, SLNB may be justified when the likelihood of node positivity is at least 10%, but the procedure is currently being ordered by clinicians even when risk of positivity is lower. Furthermore, the overall survival rates for patients with thin melanomas are excellent, ranging from 85%<span class="elsevierStyleHsp" style=""></span>to 99%, and patients with melanomas less than 1<span class="elsevierStyleHsp" style=""></span>mm thick are becoming the largest group (accounting for 60% to 70% of new diagnoses in large hospitals). Forty-four percent of our patients who underwent SLNB had tumors with a Breslow thickness of less than 1<span class="elsevierStyleHsp" style=""></span>mm, and in that group only 1 patient (2.2%) had a positive node.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Thus, 43 node-negative SLNBs and 1 node-positive SLNB were performed in this subgroup. Given that SLNB ranges in cost from €9486.57 to €10 471.29, the cost of detecting a single positive node in the group of patients with melanomas less than 1<span class="elsevierStyleHsp" style=""></span>mm thick was between €417 409.08 and €460 736.76 in our series. Patients were enrolled in this study over a 3-year period, suggesting an incidence of 0.33 node-positive cases per year. Thus, the estimated annual cost would have been €137 744.97 to €152 043.13.</p><p id="par0125" class="elsevierStylePara elsevierViewall">If pathologic assessment were extended only to the melanoma excision scar, the cost would have been €1791.41; multiplied by 44 patients the total would be €78 822.04.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Therefore, SLNB leads to a total cost increase of €338 587.04 to €381 914.72; per patient, the increase attributable to SLNB would be €7695.16 to €8679.88.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Agnese et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> calculated a loss of 17.1 years of life per melanoma. Dividing the increased cost generated by SLNB by the loss of potentially lost years of life suggests an estimated cost of €19 800.40 to €22 334.19 for each year of life saved. The literature suggests a figure of approximately $35 000 (about €27 000) as the upper limit considered reasonable to spend on SLNB per life saved.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">13,14</span></a> This purely economic indicator is very difficult to evaluate, but in theory the amounts we calculated suggest that our costs fall within the recommended limits.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Our method for calculating the cost per year of life saved was based on the approach of Agnese et al.,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> who estimated the cost to be €43 156.26 in a series of 99 melanomas with a Breslow thickness less than 1<span class="elsevierStyleHsp" style=""></span>mm. This figure was higher than in our study, and the authors had to assess 91 cases to find a single positive node. They concluded that SLNB does not appear to be cost-effective and that it should be questioned in cases of thin melanomas.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Our cost-effectiveness data suggest that the selection of patients for SLNB should be improved, especially in thin tumors (Breslow thickness less than 1<span class="elsevierStyleHsp" style=""></span>mm), given that the procedure is costly and, in our practice setting, the diagnostic yield is low in this subgroup of patients. These concerns are important at this time because new approaches to treatment for metastatic melanoma could be useful adjuncts to therapy in the near future.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> It is therefore crucial to be able to identify melanomas that have reached the node, so that such new treatments could be offered if necessary.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Optimal use of SLNB should be based on improving patient selection and standardizing the histopathologic processing protocol to establish one that is sensitive but also simple. Optimization is a dynamic process and is being intensely debated at this time. Studies in larger cohorts will be required so that conclusions can be based on more data.</p><p id="par0155" class="elsevierStylePara elsevierViewall">This study analyzed the costs of SLNB in our hospital. Even though further analyses are needed, our calculations give some indication of what is being spent. Our data can serve to raise awareness of economic issues related to the use of SLNB in teams carrying out the procedure.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical Disclosures</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of human and animal subjects</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Data confidentiality</span>. The authors declare that no private patient data are disclosed in this article.</p><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Right to privacy and informed consent</span>. The authors declare that no private patient data are disclosed in this article.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of Interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1774116" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1558313" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1774117" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Discusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1558314" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "SLNB Technique" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Histologic Processing" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Fee and Price Schedule" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0040" "titulo" => "Ethical Disclosures" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Protection of human and animal subjects" ] ] ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-15" "fechaAceptado" => "2014-10-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1558313" "palabras" => array:2 [ 0 => "Melanoma" 1 => "Sentinel lymph node biopsy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1558314" "palabras" => array:2 [ 0 => "Melanoma" 1 => "Biopsia del ganglio centinela" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sentinel lymph node biopsy (SLNB) is the most useful tool for node staging in melanoma. SLNB facilitates selective dissection of lymph nodes, that is, the performance of lymphadenectomy only in patients with sentinel nodes positive for metastasis. Our aim was to assess the cost of SLNB, given that this procedure has become the standard of care for patients with melanoma and must be performed whenever patients are to be enrolled in clinical trials. Furthermore, the literature on the economic impact of SLNB in Spain is scarce.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">From 2007 to 2010, we prospectively collected data for 100 patients undergoing SLNB followed by transhilar bivalving and multiple-level sectioning of the node for histology. Our estimation of the cost of the technique was based on official pricing and fee schedules for the Spanish region of Murcia.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The rate of node-positive cases in our series was 20%, and the mean number of nodes biopsied was 1.96; 44% of the patients in the series had thin melanomas. The total cost was estimated at between €9486.57 and €10<span class="elsevierStyleHsp" style=""></span>471.29. Histopathology accounted for a considerable portion of the cost (€5769.36).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The cost of SLNB is high, consistent with amounts described for a US setting. Optimal use of SLNB will come with the increasingly appropriate selection of patients who should undergo the procedure and the standardization of a protocol for histopathologic evaluation that is both sensitive and easy to perform.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La técnica de la biopsia selectiva del ganglio centinela (BSGC) es la mejor herramienta para la estadificación ganglionar en el melanoma, permitiendo la realización de una linfadenectomía selectiva, es decir, reservada solo a aquellos pacientes que muestran el GC positivo para metástasis. Nuestro objetivo fue evaluar el coste económico de la técnica de la BSGC, ya que se ha convertido en el procedimiento recomendado como estándar en la atención al paciente con melanoma, y es necesaria para la inclusión de los pacientes en los ensayos clínicos. Existe además escasa bibliografía en nuestro medio sobre su relevancia económica.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">De forma prospectiva se recogieron 100 pacientes a los que se realizó la técnica entre los años 2007-2010 con un procesamiento histológico transhiliar bivalvo multisecciones. Realizamos un cálculo aproximado del precio de la técnica utilizando las tarifas de precios oficiales de la Región de Murcia.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El porcentaje de positividad de nuestra serie fue del 20%, con un número medio de ganglios de 1,96 y un 44% de melanomas delgados. El precio total de la técnica es de 9.486,57-10.471,29 euros, siendo una parte muy importante de la misma atribuible al procesamiento histopatológico (5.769,36 euros).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La técnica de la BSGC tiene un precio muy considerable, aunque en consonancia con otras referencias americanas previamente descritas. La optimización de la técnica vendrá dada en función de la selección cada vez más adecuada de los pacientes que deben someterse a ella, y a la estandarización de un modelo histopatológico sensible en la detección, pero a la vez sencillo en el procesamiento.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Discusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as: Martínez-Menchón T, Sánchez-Pedreño P, Martínez-Escribano J, Corbalán-Vélez R, Martínez-Barba E. Evaluación del coste económico de la técnica de la biopsia selectiva del ganglio centinela en melanoma. Actas Dermosifiliogr. 2015;106:201–207.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1587 "Ancho" => 3003 "Tamanyo" => 226661 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagram illustrating how the sentinel node sections were obtained and processed. A, Transhilar bivalving. B, Parallel processing (breadloafing).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1249 "Ancho" => 757 "Tamanyo" => 113294 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Sections obtained from histologic processing of a single sentinel node.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2007–2010 Series \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Mean Breslow thickness, mm</span> \t\t\t\t\t\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">2.02 \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Sex</span></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"><span class="elsevierStyleHsp" style=""></span>Men \t\t\t\t\t\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">41 (41.41%) \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"><span class="elsevierStyleHsp" style=""></span>Women \t\t\t\t\t\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">58 (58.58%) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Location</span></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"><span class="elsevierStyleHsp" style=""></span>Limbs \t\t\t\t\t\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">42 (42.85%) \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"><span class="elsevierStyleHsp" style=""></span>Trunk \t\t\t\t\t\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">49 (50%) \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"><span class="elsevierStyleHsp" style=""></span>Head and neck \t\t\t\t\t\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">7 (7.15%) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Findings of histopathology</span></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"><span class="elsevierStyleHsp" style=""></span>Negative \t\t\t\t\t\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 (79.79%) \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"><span class="elsevierStyleHsp" style=""></span>Positive \t\t\t\t\t\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">20 (20.20%) \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"><span class="elsevierStyleHsp" style=""></span>Isolated cells \t\t\t\t\t\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">4 (4.04%) \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"><span class="elsevierStyleHsp" style=""></span>Micrometastasis \t\t\t\t\t\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">3 (3.03%) \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"><span class="elsevierStyleHsp" style=""></span>Macrometastasis \t\t\t\t\t\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">13 (13.13%) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">No. of nodes excised</span></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"><span class="elsevierStyleHsp" style=""></span>1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 (51.51%) \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"><span class="elsevierStyleHsp" style=""></span>2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (28.28%) \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"><span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (20.20%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Main Characteristics of the Patient Series.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: ICD-9-CM, International Classification of Diseases, 9th Revision, Clinical Modification; SLNB, sentinel lymph node biopsy.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Item \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cost, € \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conventional hospitalization per day; price code, A.1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">583.60 \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">Radical excision of skin lesion (with safety margins), ICD-9-CM.86.40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1726.28 \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">Skin graft or flap, ICD-9-CM.86.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1726.28 \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">Nuclear medicine study, sentinel node in melanoma; price code, A.5.1.N.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">200.38 \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">Axillary lymph node excision, ICD-9-CM.40.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1206.95 \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">Inguinal lymph node excision, ICD-9-CM.40.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2191.67 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">General Costs Necessary for SLNB, Excluding Histopathologic Processing Costs.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stain \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Unit Price, € \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total Price, € \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H&E \t\t\t\t\t\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">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">586.17 \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">Anti-Melan A \t\t\t\t\t\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">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">766.17 \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">Anti-S100 \t\t\t\t\t\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">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">766.17 \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">Anti-HMB-45 \t\t\t\t\t\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">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">766.17 \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">Total \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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">2884.68 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Costs Related to the Histopathologic Processing of Sentinel Lymph Nodes.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Abbreviation: H&E, hematoxylin and eosin.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Processing Technique \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Multiple-Level Sectioning \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No. of Sections \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Staining \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">% <a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanknebel (routine pathology) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transhilar bivalving \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 level \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 frozen, 1 paraffin-embedded \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H&E \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \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">Spanknebel (extended pathology) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transhilar bivalving \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 levels, every 50<span class="elsevierStyleHsp" style=""></span>μ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H&E, anti-S100, anti-HMB-45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 \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">Cook (protocol 1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transhilar bivalving \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not done \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H&E, anti-S100, anti-HMB-45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \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">Cook (protocol 2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transhilar bivalving \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 levels, every 50<span class="elsevierStyleHsp" style=""></span>μ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H&E, anti-S100, anti-HMB-45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \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">Cook (protocol 3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transhilar bivalving \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 levels, every 50<span class="elsevierStyleHsp" style=""></span>μ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H&E, anti-S100, anti-HMB-45, Pan Melanoma Plus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \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">Abrahamsen \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transhilar bivalving \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Every 250<span class="elsevierStyleHsp" style=""></span>μ (entire node) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">According to size of node \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H&E, anti-S100, anti-HMB-45, anti-Melan-A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 \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">Bostick, Takeuchi \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transhilar bivalving \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80<span class="elsevierStyleHsp" style=""></span>μ frozen<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>3 levels every 40<span class="elsevierStyleHsp" style=""></span>μ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4–16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H&E, anti-S100, anti-HMB-45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \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">Starz \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parallel to the longitudinal axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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<span class="elsevierStyleHsp" style=""></span>mm, with scalpel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">According to size of node \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H&E, anti-S100, anti-HMB-45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \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">Li \t\t\t\t\t\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"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 level \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H&E, anti-S100, anti-HMB-45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \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">Rimoldi \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parallel to the shortest diameter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2–3<span class="elsevierStyleHsp" style=""></span>mm, with scalpel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12–20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H&E, anti-S100, anti-HMB-45, anti-tyrosinase, anti-Melan-A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Adapted from Mangas et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a></p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">When authors describe more than one process, the technique is named in parentheses.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Percentage of positive nodes found.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Summary of Approaches to Assessment of the Sentinel Node<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prognostic factors analysis of 17,600 melanoma patients: Validation of the American Joint Committee on Cancer melanoma staging system" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.M. Balch" 1 => "S.J. Soong" 2 => "J.E. Gershenwald" 3 => "J.F. Thompson" 4 => "D.S. Reintgen" 5 => "N. Cascinelli" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Clin Oncol" "fecha" => "2001" "volumen" => "19" "paginaInicial" => "3622" "paginaFinal" => "3634" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0085" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitotic rate as a predictor of sentinel lymph node positivity in patients with thin melanomas" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.B. Kesmodel" 1 => "G.C. Karakousis" 2 => "J.D. Botbyl" 3 => "R.J. Canter" 4 => "R.T. Lewis" 5 => "P.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 6 | 14 |
| 2024 October | 110 | 36 | 146 |
| 2024 September | 117 | 23 | 140 |
| 2024 August | 145 | 53 | 198 |
| 2024 July | 171 | 36 | 207 |
| 2024 June | 145 | 30 | 175 |
| 2024 May | 165 | 30 | 195 |
| 2024 April | 137 | 25 | 162 |
| 2024 March | 119 | 40 | 159 |
| 2024 February | 110 | 34 | 144 |
| 2024 January | 97 | 30 | 127 |
| 2023 December | 64 | 20 | 84 |
| 2023 November | 76 | 25 | 101 |
| 2023 October | 68 | 43 | 111 |
| 2023 September | 65 | 31 | 96 |
| 2023 August | 44 | 16 | 60 |
| 2023 July | 52 | 39 | 91 |
| 2023 June | 52 | 22 | 74 |
| 2023 May | 88 | 34 | 122 |
| 2023 April | 48 | 15 | 63 |
| 2023 March | 79 | 36 | 115 |
| 2023 February | 52 | 23 | 75 |
| 2023 January | 61 | 24 | 85 |
| 2022 December | 55 | 34 | 89 |
| 2022 November | 35 | 27 | 62 |
| 2022 October | 23 | 14 | 37 |
| 2022 September | 23 | 45 | 68 |
| 2022 August | 24 | 37 | 61 |
| 2022 July | 28 | 36 | 64 |
| 2022 June | 17 | 20 | 37 |
| 2022 May | 33 | 42 | 75 |
| 2022 April | 45 | 33 | 78 |
| 2022 March | 50 | 49 | 99 |
| 2022 February | 28 | 18 | 46 |
| 2022 January | 44 | 39 | 83 |
| 2021 December | 27 | 39 | 66 |
| 2021 November | 47 | 35 | 82 |
| 2021 October | 42 | 55 | 97 |
| 2021 September | 32 | 35 | 67 |
| 2021 August | 23 | 27 | 50 |
| 2021 July | 14 | 28 | 42 |
| 2021 June | 43 | 32 | 75 |
| 2021 May | 39 | 22 | 61 |
| 2021 April | 91 | 55 | 146 |
| 2021 March | 50 | 25 | 75 |
| 2021 February | 50 | 33 | 83 |
| 2021 January | 35 | 16 | 51 |
| 2020 December | 40 | 20 | 60 |
| 2020 November | 31 | 19 | 50 |
| 2020 October | 23 | 14 | 37 |
| 2020 September | 34 | 15 | 49 |
| 2020 August | 28 | 17 | 45 |
| 2020 July | 25 | 13 | 38 |
| 2020 June | 42 | 20 | 62 |
| 2020 May | 34 | 20 | 54 |
| 2020 April | 42 | 14 | 56 |
| 2020 March | 27 | 15 | 42 |
| 2020 February | 2 | 1 | 3 |
| 2020 January | 1 | 0 | 1 |
| 2019 December | 8 | 2 | 10 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 6 | 10 | 16 |
| 2019 April | 3 | 1 | 4 |
| 2019 March | 4 | 7 | 11 |
| 2019 February | 4 | 0 | 4 |
| 2019 January | 3 | 2 | 5 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 3 | 0 | 3 |
| 2018 October | 7 | 0 | 7 |
| 2018 September | 3 | 0 | 3 |
| 2018 March | 2 | 0 | 2 |
| 2018 February | 23 | 4 | 27 |
| 2018 January | 32 | 7 | 39 |
| 2017 December | 29 | 5 | 34 |
| 2017 November | 31 | 5 | 36 |
| 2017 October | 22 | 7 | 29 |
| 2017 September | 17 | 8 | 25 |
| 2017 August | 27 | 3 | 30 |
| 2017 July | 17 | 3 | 20 |
| 2017 June | 31 | 5 | 36 |
| 2017 May | 22 | 3 | 25 |
| 2017 April | 25 | 10 | 35 |
| 2017 March | 19 | 8 | 27 |
| 2017 February | 25 | 5 | 30 |
| 2017 January | 15 | 7 | 22 |
| 2016 December | 42 | 5 | 47 |
| 2016 November | 31 | 6 | 37 |
| 2016 October | 29 | 9 | 38 |
| 2016 September | 0 | 9 | 9 |
| 2016 July | 14 | 5 | 19 |
| 2016 June | 14 | 1 | 15 |
| 2016 May | 10 | 1 | 11 |
| 2016 April | 11 | 0 | 11 |
| 2016 March | 9 | 1 | 10 |
| 2016 February | 8 | 3 | 11 |
| 2016 January | 4 | 6 | 10 |
| 2015 December | 8 | 8 | 16 |
| 2015 November | 9 | 4 | 13 |
| 2015 October | 7 | 9 | 16 |
| 2015 September | 0 | 8 | 8 |
| 2015 August | 0 | 3 | 3 |
| 2015 July | 12 | 6 | 18 |
| 2015 June | 12 | 9 | 21 |
| 2015 May | 3 | 7 | 10 |
| 2015 April | 0 | 8 | 8 |
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