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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Melanoma is a neoplasm that&#44; despite its small size&#44; has a relatively high ability to metastasize&#44; occasionally early&#46; Its incidence and mortality have increased in recent decades&#44; especially in whites&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">When establishing the prognosis of a patient with cutaneous melanoma&#44; the most important factors to be taken into account are presence of metastasis&#44; type and number of affected organs&#44; and&#8212;if these data are not available&#8212;the thickness of the tumor and the presence of ulceration&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3-5</span></a> Since it was first introduced in 1992&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a> sentinel lymph node biopsy &#40;SLNB&#41; has become the main locoregional staging technique&#44; making it possible to provide an accurate prognosis in patients with clinical and radiological evidence of localized disease &#40;clinical stages I and II of the American Joint Committee on Cancer&#41;&#46; Although SLNB is not particularly invasive&#44; it is not free of complications&#44; especially local complications such as seroma&#44; hematoma&#44; and surgical wound infection and&#44; albeit more rarely&#44; lymphedema&#46; Furthermore&#44; the technique requires patients to receive general or spinal anesthesia&#44; with all its concomitant risks&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Performing additional radiological tests continues to be controversial&#44; as the low rate of detection does not justify the costs&#46; The tests themselves are expensive and can reveal incidentalomas &#40;findings not related to melanoma that require new tests for characterization&#41;&#46; Testing also causes anxiety for patients&#46; Nevertheless&#44; it seems reasonable to use financially and clinically profitable techniques that obviate SLNB in cases where it is not necessary&#46; Several studies have evaluated a series of procedures &#40;traditional ultrasound&#44; high-resolution ultrasound&#44; ultrasound-guided fine-needle aspiration&#44; contrast ultrasound&#44; and positron-emission tomography&#47;computed tomography&#41; in staging before SLNB&#44; with diverse results&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">7-17</span></a> However&#44; few studies consider the cost-effectiveness of these procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of the present study is to evaluate the role of ultrasound&#44; including ultrasound-guided biopsy &#40;UGB&#41; when necessary&#44; as a staging technique before SLNB&#46; The study aims to determine the percentage of cases in which it is possible to avoid SLNB and the cost-effectiveness of this approach in our setting&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We designed a retrospective observational study based on data collected from our institutional melanoma database&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study population comprised all patients with cutaneous melanoma who had undergone lymph node ultrasound before SLNB as part of their staging study between January 1&#44; 2004 and December 31&#44; 2015 at the Instituto Valenciano de Oncolog&#237;a&#44; Valencia&#44; Spain&#46; Therefore&#44; we excluded patients in whom lymph node metastasis had been detected during the physical examination &#40;palpable enlarged nodes confirmed by histopathology&#41;&#46; We also excluded patients with mucosal&#44; uveal&#44; and unknown primary melanomas&#44; as well as those with insufficient information on the result of the lymph node biopsy&#44; UGB&#44; or SLNB &#40;ie&#44; patients whose sentinel node was not identified were excluded&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study was approved by the local ethics committee&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">At our center&#44; SLNB is performed in patients with melanomas measuring more than 0&#46;75<span class="elsevierStyleHsp" style=""></span>mm and in patients with thinner melanomas and any of the following risk factors&#58; ulceration&#44; presence of at least 1 mitosis&#47;mm<span class="elsevierStyleSup">2</span>&#44; microscopic satellite lesions&#47;vascular invasion&#44; regression greater than 50&#37;&#44; or incomplete excision with an affected deep margin &#40;regression stopped being used as a selection criterion in January 2015 after it was shown to be of no value for predicting sentinel node involvement&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">19&#44;20</span></a> Patients with primary cutaneous melanoma who fulfilled the criteria for SLNB were systematically evaluated beforehand as part of the staging study using B-flow and Doppler lymph node ultrasound&#46; Ultrasound was performed by 2 experienced radiologists &#40;CD and MG&#41;&#46; Lymph nodes were classified as benign&#44; indeterminate&#44; or suspicious for melanoma according to standard criteria &#40;see above&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The ultrasound examination covered all possible drainage territories depending on the site&#46; In the case of indeterminate or suspicious findings&#44; an ultrasound-guided core-needle biopsy &#40;Tru-cut&#41; was performed&#46; Histopathology of the biopsies performed included hematoxylin-eosin study and immunohistochemistry &#40;S100 and melan-A&#41;&#46; In patients whose histology work-up revealed melanoma cells&#44; therapeutic lymph node dissection of the affected lymphatic basin was performed directly&#46; The remaining patients underwent SLNB&#44; followed by therapeutic lymph node dissection if melanoma cells were present&#46; The technique used to evaluate sentinel nodes at our center has been reported in detail elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The study endpoints were as follows&#58; &#40;<span class="elsevierStyleItalic">1</span>&#41; the percentage of cases in which SLNB was obviated based on core-needle biopsy and ultrasound&#59; &#40;<span class="elsevierStyleItalic">2</span>&#41; the clinical yield of core-needle biopsy in indeterminate and suspicious malignant nodes &#40;both together and separately&#41;&#59; &#40;<span class="elsevierStyleItalic">3</span>&#41; false negatives in ultrasound&#59; &#40;<span class="elsevierStyleItalic">4</span>&#41; the cost-effectiveness ratio of initial staging of patients with melanoma depending on whether or not regional lymph node ultrasound was performed before SLNB&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical and Cost Analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">We used contingency tables and calculated the sensitivity&#44; specificity&#44; positive predictive value&#44; and negative predictive value for the ability to detect metastasis in both SLNB and UGB&#46; For purposes of the study&#44; true positives were defined as indeterminate or positive ultrasound scans with histologic confirmation using either core-needle biopsy or SLNB&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">False positives were defined as indeterminate and positive ultrasound scans without lymph node metastasis&#44; both in core-needle biopsy and in SLNB&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">True negatives were defined as normal ultrasound scans with negative SLNB results&#59; false negatives were defined as normal ultrasound scans with positive SLNB results&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The statistical analysis was performed using SPSS 20&#46;0 &#40;IBM Corp&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The cost analysis consisted of a cost-effectiveness study from the health service perspective&#46; The study compared the efficiency of 2 theoretical protocols for staging patients with melanoma&#58; one in which regional lymph node ultrasound was performed during the initial phase of staging and one in which it was not &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">In protocol A&#44; lymph node ultrasound was not performed during initial staging&#59; therefore&#44; all selected patients underwent SLNB&#46; In protocol B&#44; all patients underwent regional lymph node ultrasound&#44; as well as core-needle biopsy in cases where the results were indeterminate or positive&#46; Patients in whom core-needle biopsy confirmed the presence of lymph node metastasis did not undergo SLNB &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; selection&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Based on the set of activities presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; activity-based costing was applied to assign specific costs to the activities carried out in each of the protocols &#40;lymph node ultrasound&#44; core-needle biopsy&#44; SLNB&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Common activities and activities with foreseeably indistinguishable results in both protocols were excluded from the assignation of costs &#40;physical examination&#41;&#46; Costs were assigned to each activity by applying the rates in force in the health system where the study was performed&#44; as follows&#58; lymph node ultrasound&#44; &#8364;35&#59; core-needle biopsy&#44; &#8364;280&#59; SLNB&#44; &#8364;1700&#46; The prices set are the costs invoiced to third parties for these services and include direct and indirect costs arising from the activity of the center&#46; These costs per activity and the frequency of events observed &#40;lymph node metastasis identified&#41; were used to calculate the unit costs &#40;&#8364;&#47;patient&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; These costs and the probability of events in each protocol were used to design a decision tree &#40;TreeAge Pro 2016&#44; TreeAge Software Inc&#46;&#41; to calculate the cost-effectiveness ratio for each protocol and to identify the dominant strategy &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The frequency of lymph node metastasis in each of the protocols compared was considered as a measure of effectiveness&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">A total of 384 patients fulfilled the selection criteria and were included in the study &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The result of the ultrasound scan was normal in 270 patients&#44; indeterminate in 97&#44; and positive in 17 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Consistent with the data recorded &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; ultrasound as a technique for the detection of metastatic lymph nodes had a sensitivity of 46&#37;&#44; specificity of 76&#37;&#44; positive predictive value of 41&#37;&#44; negative predictive value of 79&#37;&#44; and false-negative rate of 20&#37;&#46; Of the 97 patients whose ultrasound findings were indeterminate&#44; lymph node metastasis was eventually detected in 33 patients &#40;34&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The results of the analysis of the yield of ultrasound-guided core-needle biopsy are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Of the 114 patients whose findings were indeterminate or positive&#44; 104 underwent core-needle biopsy&#46; Of the 87 patients with an indeterminate result who underwent core-needle biopsy&#44; the result was negative in 73 &#40;83&#46;9&#37;&#41; and positive in 14 &#40;16&#46;1&#37;&#41; &#40;sensitivity<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>42&#37;&#59; specificity<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>84&#46;4&#37;&#41;&#46; Of the 17 patients whose ultrasound results led us to suspect malignancy and in those who underwent UGB&#44; the result was negative in 8 patients &#40;40&#37;&#41; and positive in 9 &#40;45&#37;&#41; &#40;sensitivity<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>64&#37;&#59; specificity<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>66&#46;7&#37;&#41;&#46; The biopsy material was insufficient in 3 of the patients with an indeterminate result and in 3 of the patients with a positive result &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Overall&#44; the sensitivity of core-needle biopsy was calculated to be 22&#46;5&#37;&#44; specificity 19&#46;8&#37;&#44; positive predictive value 100&#37;&#44; and negative predictive value 74&#46;6&#37;&#46; Of the total number of patients who underwent core-needle biopsy with sufficient material for analysis&#44; the percentage of positive nodes was 16&#46;6&#37; &#40;14&#47;84&#41; in patients with an indeterminate ultrasound result and 64&#37; &#40;9&#47;14&#41; in those with a positive ultrasound result&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">SLNB was performed in 361 patients&#58; the result was negative in 282 cases and positive in 79&#46; The percentage of positive sentinel nodes with a negative core-needle biopsy result &#40;false negatives&#41; was 22&#46;8&#37; &#40;16&#47;70&#41; in the group with indeterminate ultrasound findings and 60&#37; &#40;3&#47;5&#41; in the group with positive ultrasound findings&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">An evaluation of the 55 false negatives by ultrasound revealed a statistically significant percentage of false negatives in patients aged &#62;<span class="elsevierStyleHsp" style=""></span>60 years and for a Breslow thickness of &#60;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mm&#46; Findings for the remaining factors studied were not statistically significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Finally&#44; we analyzed the costs generated by ultrasound&#44; and the resulting UGB&#44; before SLNB&#46; Our results showed that SLNB was obviated in 23 patients &#40;6&#37;&#41;&#46; The activity-based costing approach revealed a unit cost of &#8364;1700&#46;00 per patient staged by SLNB alone and &#8364;1716&#46;30 per patient staged by SLNB preceded by ultrasound&#46; In terms of cost-effectiveness&#44; the analysis revealed ultrasound followed by SLNB to be the dominant strategy&#44; with a cost-effectiveness ratio lower than the alternative&#44; ie&#44; SLNB alone &#40;&#8364;8095&#46;24 vs &#8364;28&#160;605&#46;00&#160;&#8364;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Our study confirms data reported in the literature with respect to the value of ultrasound as a method for locoregional staging of melanoma&#44; namely&#44; the method is useful&#44; although not sufficiently accurate to replace SLNB as the technique of choice&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">7-17</span></a> It is noteworthy that lymph node metastasis was detected in 34&#37; of patients with indeterminate ultrasound results&#46; In these patients&#44; the characteristics of the ultrasound examination neither confirmed metastasis nor enabled it to be ruled out&#46; Furthermore&#44; UGB made it possible to detect metastasis in more than half of all patients with positive ultrasound results&#46; Given that UGB also presented a percentage of false negatives&#44; a negative result indicates that staging should be completed using SLNB&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The main advantage of UGB before SLNB is that it obviates SLNB in cases where metastasis is detected using UGB alone&#46; In our series&#44; UGB obviated SLNB in 23 of 384 patients &#40;6&#37;&#41;&#46; Even though this is not a large number&#44; UGB before SLNB is considerably advantageous for patients who could benefit from it&#44; since SLNB&#44; despite being a minimally invasive procedure&#44; is not free from complications&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Furthermore&#44; the cost-effectiveness analysis showed that&#44; for the cases in the present series&#44; ultrasound for initial staging in patients with melanoma generates an additional cost of &#8364;16&#46;30 per patient&#46; This cost represents a 0&#46;96&#37; increase in the cost of staging patients with melanoma and is an additional cost that can be considered acceptable for most health services&#44; especially if we take into account the low-to-medium incidence of melanoma in Spain &#40;8&#46;76&#59; 95&#37; CI&#44; 7&#46;50-10&#46;02&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> Thus&#44; in the case of a hospital with a reference population of 500&#160;000 inhabitants and an expected incidence of 40-50 cases&#47;year and assuming that 50&#37; of cases are diagnosed as melanoma in situ or T1&#44; with no indication for SLNB&#44; the inclusion of ultrasound during initial staging would represent an annual total extra cost of between &#8364;350 and &#8364;450&#44; which most health services can afford&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">23&#44;24</span></a> In addition&#44; the cost of performing ultrasound on all of the patients &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>384&#41; and the lymph node biopsies performed to confirm ultrasound findings suspected of being malignant &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>104&#41; was partially compensated by the 23 SLNBs avoided &#40;&#8364;42&#160;560 vs &#8364;39&#160;100&#41;&#46; This increase in total costs translated into an increase of &#8364;150&#46;43 for each SLNB avoided&#44; ie&#44; 8&#46;85&#37; of the cost of performing SLNB&#46; Despite the low morbidity of SLNB&#44; the additional cost of &#8364;150 for obviating the procedure could be considered acceptable&#44; thus favoring the implementation of ultrasound&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Similarly&#44; taking the identification of lymph node metastasis as a measure of effectiveness&#44; the extra unit cost of &#8364;16 was easily compensated by the high frequency of identification of lymph node metastasis in patients with a positive lymph node ultrasound result&#46; This advantage of effectiveness &#40;0&#46;06 vs 0&#46;21&#41; generated an incremental cost-effectiveness ratio that showed the staging protocol based on ultrasound and SLNB to be the more cost-effective strategy and&#44; therefore&#44; better than staging by SLNB&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The limitations of the present study are that it was performed at a single center and&#44; as a retrospective study&#44; lacked randomization and a control group&#46; With respect to core-needle biopsy&#44; we obtained lower sensitivity and specificity than other authors&#44; thus necessitating an analysis of the possible causes and a plan for improvement in causes that can be rectified&#46; A potential explanation could be that the patients in the present study had a lower Breslow thickness than in other studies&#46; They may have even had a lower metastatic burden&#44; with greater difficulty for obtaining a suitable sample in core-needle biopsy&#59; this hypothesis could be supported by the greater percentage of false negatives found in thinner tumors&#46; Evaluating such a hypothesis would require a subgroup analysis and subsequent comparison with the results of other authors&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In conclusion&#44; ultrasound&#8212;including UGB when necessary&#8212;is a useful and cost-effective diagnostic tool for staging melanoma before SLNB&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical Disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of Humans and Animals</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purposes of this study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of Data</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have followed their institutional protocols on publication of patient data&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to Privacy and Informed Consent</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of Interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Locoregional lymph node ultrasound is not typically included in guidelines as part of the staging process prior to sentinel lymph node biopsy &#40;SLNB&#41;&#46; The objective of the present study was to make a clinical and economic analysis of lymph node ultrasound prior to SLNB&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective study of 384 patients with clinical stage <span class="elsevierStyleSmallCaps">I</span>-<span class="elsevierStyleSmallCaps">II</span> primary melanoma who underwent locorregional lymph node ultrasound &#40;with or without ultrasound-guided biopsy&#41; prior to SLNB between 2004 and 2015&#46; We evaluated the reliability and cost-effectiveness of the strategy&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Use of locorregional lymph node ultrasound avoided SLNB in 23 patients &#40;6&#37;&#41;&#46; Ultrasound had a sensitivity of 46&#37; and specificity of 76&#37; for the detection of metastatic lymph nodes that were not clinically palpable&#46; False negatives were significantly more common in patients aged over 60 years and in tumors with a thickness of less than 2<span class="elsevierStyleHsp" style=""></span>mm&#46; The staging process using SLNB and ultrasound with ultrasound-guided biopsy produced an increase of &#8364;16&#46;30 in the unit price&#46; Our cost-effectiveness analysis identified the staging protocol with ultrasound and SLNB as the dominant strategy&#44; with a lower cost-effectiveness ratio than the alternative&#44; consisting of SLNB alone &#40;8&#44;095&#46;24 vs &#8364;28&#44;605&#46;00&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ultrasound with ultrasound-guided biopsy for the diagnostic staging of melanoma prior to SLNB is a useful and cost-effective tool&#46; This procedure does not substitute SLNB&#44; though it does allow to avoid SLNB in a not insignificant proportion of patients&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Background and objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La ecograf&#237;a ganglionar locorregional como parte de la estadificaci&#243;n previa a la biopsia del ganglio centinela &#40;BSGC&#41; en pacientes con melanoma no se incluye habitualmente en las gu&#237;as de manejo&#46; El objetivo de este estudio es evaluarla desde la perspectiva cl&#237;nica y econ&#243;mica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de 384 pacientes con melanoma primario de estadios cl&#237;nicos <span class="elsevierStyleSmallCaps">I</span>-<span class="elsevierStyleSmallCaps">II</span>&#44; en el periodo 2004-2015&#44; a los que se les realiz&#243; una ecograf&#237;a ganglionar locorregional &#40;&#177;biopsia ecodirigida&#41; previa a la BSGC&#46; Se evalu&#243; la fiabilidad de la t&#233;cnica y se realiz&#243; un an&#225;lisis de su coste efectividad&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En 23 pacientes &#40;6&#37;&#41; se pudo evitar la realizaci&#243;n de la BSGC mediante la t&#233;cnica&#46; La ecograf&#237;a mostr&#243; una sensibilidad del 46&#37; y una especificidad del 76&#37; para la detecci&#243;n de ganglios metast&#225;sicos cl&#237;nicamente no palpables&#46; Los falsos negativos fueron significativamente m&#225;s frecuentes en pacientes mayores de 60 a&#241;os y con tumores &#60;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mm&#46; El coste unitario del proceso de estadificaci&#243;n mediante BSGC con ecograf&#237;a-biopsia ecodirigida gener&#243; un sobrecoste de 16&#44;30&#160;&#8364;&#46; El an&#225;lisis coste-efectividad identific&#243; como estrategia dominante desde ese punto de vista el protocolo de estadificaci&#243;n con ecograf&#237;a y BSGC&#44; con una ratio coste-efectividad inferior a la de la alternativa consistente en BSGC &#40;8&#46;095&#44;24 vs 28&#46;605&#44;00&#160;&#8364;&#41;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La ecograf&#237;a con biopsia ecodirigida como m&#233;todo diagn&#243;stico de estadificaci&#243;n previo a la BSGC es una herramienta &#250;til y coste-efectiva&#44; que no sustituye a la BSGC&#44; pero que permite en un porcentaje no desde&#241;able de casos evitar su realizaci&#243;n&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n y objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Pacientes y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:3 [
        "etiqueta" => "1"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">These authors have contributed equally to the article&#46;</p>"
        "identificador" => "fn0005"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Olmedo D&#44; et al&#46; Valor de la ecograf&#237;a ganglionar previa a la biopsia del ganglio centinela en 384 pacientes con melanoma&#58; an&#225;lisis de coste-efectividad&#46; Actas Dermosifiliogr&#46; 2017&#59;108&#58;931&#8211;938&#46;</p>"
      ]
    ]
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Comparison of Stratification Protocols&#46; SLNB indicates sentinel lymph node biopsy&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Decision Tree for the Cost-effectiveness Analysis&#46; SLNB indicates sentinel lymph node biopsy&#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" => 2178
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Flow Diagram&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; SLNB&#44; sentinel lymph node biopsy&#46;</p>"
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              "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="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Protocol A</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Protocol B</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ultrasound&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Lymph Node Biopsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SLNB Performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Unit Cost&#44; &#8364;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SLNB Performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Unit Cost&#44; &#8364;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Not performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">384&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">384&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1700&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1735&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Indeterminate</td><td class="td" title="table-entry  " align="left" valign="top">Not performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1735&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Insufficient sample material&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lymphadenitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">315&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Positive</td><td class="td" title="table-entry  " align="left" valign="top">Insufficient sample material&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lymphadenitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">315&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">384&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">361&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Procedures Performed&#44; Events &#40;Lymph Node Metastasis&#41;&#44; and Costs of the Protocols Studied&#46;</p>"
        ]
      ]
      4 => array:8 [
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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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"><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Lymph Node Ultrasound</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sentinel Node</th><th class="td" title="table-head  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td" title="table-head  " colspan="3" align="left" valign="top" scope="col" style="border-bottom: 2px solid black"></th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Not Performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Normal</td><td class="td" title="table-entry  " align="left" valign="top">Ultrasound-guided&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">215&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">215&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Indeterminate</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Ultrasound-guided</td><td class="td" title="table-entry  " align="left" valign="top">Not performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Insufficient sample material&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lymphadenitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Positive</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Ultrasound-guided</td><td class="td" title="table-entry  " align="left" valign="top">Insufficient sample material&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lymphadenitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Total</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Ultrasound-guided</td><td class="td" title="table-entry  " align="left" valign="top">Not performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">222&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">280&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Insufficient sample material&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lymphadenitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">282&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">384&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Characteristics of Patients With Respect to Lymph Node Ultrasound&#44; Ultrasound-Guided Biopsy&#44; and the Result of SLNB&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ultrasound</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Lymph Node Involvement</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">215&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Positive&#47;indeterminate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1607275.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Results of Lymph Node Ultrasound and Lymph Node Involvement at the End of the Study&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
          ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; SLNB&#44; sentinel lymph node biopsy&#59; UGB&#44; ultrasound-guided biopsy&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Protocol A SLNB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Protocol B UGB<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SLNB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unit cost &#40;&#8364;&#47;patient&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1700&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1716&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Effectiveness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cost-effectiveness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#160;605&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8095&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Incremental cost&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">16&#46;30</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Incremental effectiveness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>0&#46;15</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Incremental cost-effectiveness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>20&#46;509&#46;76</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dominated strategy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dominant strategy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1607276.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Results of the Cost-effectiveness Analysis&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:24 [
            0 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cancer incidence and mortality patterns in Europe&#58; Estimates for 40 countries in 2012"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Ferlay"
                            1 => "E&#46; Steliarova-Foucher"
                            2 => "J&#46; Lortet-Tieulent"
                            3 => "S&#46; Rosso"
                            4 => "J&#46;W&#46; Coebergh"
                            5 => "H&#46; Comber"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ejca.2012.12.027"
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