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de todos los melanomas cut&#225;neos se localizan en zonas acrales<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; Como es bien sabido&#44; todos los tipos de MM se pueden encontrar en las zonas acrales&#44; pero el subtipo m&#225;s prevalente es el MLA&#46; Dicho subtipo aparece en el dorso de las manos y de los pies&#44; en las palmas&#44; en las plantas&#44; en las mu&#241;ecas&#44; en los tobillos y en la regi&#243;n subungueal<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Aunque la incidencia del MLA parece ser similar entre las distintas razas&#44; se constata una mayor proporci&#243;n en las no cauc&#225;sicas&#44; que parece deberse a una incidencia menor del resto de MM<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La edad media de inicio del MLA es superior a la del resto de MM&#58; 59-63 a&#241;os en publicaciones previas con un pico de incidencia durante la s&#233;ptima d&#233;cada<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El MLA&#44; al igual que ocurre con el MN&#44; se diagnostica con menor frecuencia en estadios precoces respecto al MLM y al MES&#46; Este hecho podr&#237;a ser explicado por varias hip&#243;tesis no excluyentes entre s&#237;&#44; un comportamiento biol&#243;gico m&#225;s agresivo que otros tipos de MM&#44; una falta de conciencia en la poblaci&#243;n de la posibilidad de que el melanoma se presente en las regiones subungueales o palmo-plantares&#44; una presentaci&#243;n cl&#237;nica distinta a la de otros MM en otras localizaciones o la dificultad para detectar las lesiones por estar ocultas a la vista durante la vida cotidiana o por una menor atenci&#243;n hacia la salud debido al grupo de edad en el que se presenta&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">El m&#233;todo ABCDE &#40;Asimetr&#237;a&#44; Bordes irregulares&#44; cambio de Color&#44; Di&#225;metro superior a 6<span class="elsevierStyleHsp" style=""></span>mm&#44; Evoluci&#243;n&#41;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> y la lista de los 7 puntos de Glasgow &#40;cambio en tama&#241;o&#44; forma o color&#44; di&#225;metro superior a 6<span class="elsevierStyleHsp" style=""></span>mm&#44; inflamaci&#243;n&#44; exudaci&#243;n o sangrado&#44; leve prurito o cambios de sensibilidad&#41; son los 2 m&#233;todos propuestos para la detecci&#243;n de MM en estadios precoces&#46; Dada la localizaci&#243;n poco accesible&#44; y a que esta variedad es menos conocida entre la poblaci&#243;n general&#44; dado que su presentaci&#243;n podr&#237;a no ser la caracter&#237;stica del melanoma en otras localizaciones&#44; es posible que los MLA sean detectados de forma tard&#237;a&#44; tanto por el paciente como por el personal sanitario&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El objetivo del presente estudio es la descripci&#243;n de la presentaci&#243;n cl&#237;nica del MLA&#44; el patr&#243;n de detecci&#243;n y la prevalencia de los signos y s&#237;ntomas descritos en la regla del ABCDE y la lista de los 7puntos de Glasgow&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="par0040" class="elsevierStylePara elsevierViewall">Realizamos un estudio observacional retrospectivo con la base de datos de melanomas cut&#225;neos del Instituto Valenciano de Oncolog&#237;a &#40;IVO&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Se realiz&#243; un cuestionario telef&#243;nico a los pacientes con MLA sobre sus datos epidemiol&#243;gicos y la cl&#237;nica de la lesi&#243;n&#46; La descripci&#243;n de dicha lesi&#243;n fue comparada&#44; posteriormente&#44; con fotos preoperatorias en los casos en los que la imagen estuviera disponible&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se seleccionaron aquellos pacientes diagnosticados de MLA y tratados de forma definitiva en el Servicio de Dermatolog&#237;a del IVO desde enero de 1999 hasta diciembre de 2006&#46; Se incluyeron los pacientes vivos y capaces de responder a la entrevista telef&#243;nica&#46; La entrevista fue realizada durante los primeros 6 meses del a&#241;o 2007&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Para cada paciente se recogieron los siguientes datos&#58; el sexo&#44; la edad al inicio de la cl&#237;nica&#44; la edad en el momento de la extirpaci&#243;n y el nivel de estudios &#40;categorizado seg&#250;n la edad hasta la que curs&#243; estudios el paciente &#8804;<span class="elsevierStyleHsp" style=""></span>14&#44; &#8804;<span class="elsevierStyleHsp" style=""></span>18&#44; &#8804;<span class="elsevierStyleHsp" style=""></span>21&#44; &#62;<span class="elsevierStyleHsp" style=""></span>21&#44; y que puede equivaler a sin estudios&#44; estudios elementales&#44; medios o superiores&#44; respectivamente&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">En cuanto a las caracter&#237;sticas del MLA se estudiaron los antecedentes de la lesi&#243;n&#44; el motivo de consulta&#44; el retraso diagn&#243;stico y los signos y s&#237;ntomas&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><p id="par0060" class="elsevierStylePara elsevierViewall">Para los antecedentes de la lesi&#243;n se tuvo en cuenta la localizaci&#243;n&#44; si exist&#237;a una lesi&#243;n previa &#40;ninguna&#47;cong&#233;nita&#47;&#171;de toda la vida&#187;&#47;a&#241;os&#41;&#44; antecedente de traumatismos o de quemaduras &#40;ninguno&#47;leve&#47;intenso&#41; en esa localizaci&#243;n&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><p id="par0065" class="elsevierStylePara elsevierViewall">Los datos relacionados con el motivo de consulta fueron&#58; primera persona que se percat&#243; de la lesi&#243;n &#40;paciente&#47;m&#233;dico&#47;otra persona&#41;&#44; si la lesi&#243;n fue el motivo de consulta&#44; de qui&#233;n fue la idea de consultar&#44; n&#250;mero y especialidad del personal sanitario consultado y los diagn&#243;sticos previos&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><p id="par0070" class="elsevierStylePara elsevierViewall">El retraso del paciente se defini&#243; como el tiempo transcurrido entre la primera vez que se percat&#243; de la existencia de la lesi&#243;n y el momento de la consulta&#46; El retraso del m&#233;dico se defini&#243; como el tiempo transcurrido entre la primera consulta con el personal sanitario y la biopsia&#46; Ambos retrasos se clasificaron en los siguientes intervalos de tiempo&#58; &#8804;<span class="elsevierStyleHsp" style=""></span>1 mes&#44; &#62;<span class="elsevierStyleHsp" style=""></span>1 mes a &#8804;<span class="elsevierStyleHsp" style=""></span>3 meses&#44; entre &#62;<span class="elsevierStyleHsp" style=""></span>3 meses a &#8804;<span class="elsevierStyleHsp" style=""></span>6 meses&#44; entre &#62;<span class="elsevierStyleHsp" style=""></span>6 meses a &#8804;<span class="elsevierStyleHsp" style=""></span>1 a&#241;o y m&#225;s de un a&#241;o&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><p id="par0075" class="elsevierStylePara elsevierViewall">Tambi&#233;n se recogieron mediante la encuesta telef&#243;nica los signos y los s&#237;ntomas incluidos en el ABCD y en la lista de los 7 puntos de Glasgow con los que se present&#243; la lesi&#243;n&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><p id="par0080" class="elsevierStylePara elsevierViewall">Desde enero de 1999 hasta diciembre de 2006 1&#46;017 pacientes&#44; todos ellos cauc&#225;sicos&#44; fueron controlados por un melanoma cut&#225;neo en el Servicio de Dermatolog&#237;a del IVO&#46; Ochenta y cinco &#40;8&#44;36&#37;&#41; presentaban un melanoma de localizaci&#243;n acral y&#44; de ellos&#44; 46 un MLA &#40;4&#44;52&#37; del total de MM y 54&#44;1&#37; de los melanomas acrales&#41;&#44; los restantes fueron 23 melanomas de extensi&#243;n superficial&#44; 15 melanomas nodulares y un lentigo maligno melanoma&#46; De los 46 pacientes con MLA solo quedaban vivos 34&#46; De estos 34 no se pudo contactar con 8 y 3 no pudieron realizar el cuestionario telef&#243;nico &#40;uno por un infarto cerebral&#44; otro por demencia y otro por efectos secundarios del interfer&#243;n&#41;&#46; Por lo tanto&#44; de los 46 pacientes con MLA solo 23 fueron capaces de responder al cuestionario&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">De los 23 pacientes 6 eran varones y 17 mujeres&#46; Dieciocho hab&#237;an estudiado como mucho hasta los 14 a&#241;os&#44; uno hasta los 17 a&#241;os&#44; 2 ten&#237;an estudios medios y otros 2 estudios superiores&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">La edad mediana a la que los pacientes se percataron que ten&#237;an la lesi&#243;n fue de 64 a&#241;os &#40;intervalo de 39 a 85 a&#241;os&#41;&#46; La edad mediana en el momento de la extirpaci&#243;n de la lesi&#243;n fue de 66 a&#241;os &#40;intervalo de 39 a 86 a&#241;os&#41;&#46; El espesor tumoral medio y mediano fue de 3&#44;07<span class="elsevierStyleHsp" style=""></span>mm &#40;DE&#58; 2&#44;23&#41; y 2&#44;90<span class="elsevierStyleHsp" style=""></span>mm &#40;intervalo&#58; 0&#44;8-9<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; respectivamente&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La mayor&#237;a de los pacientes no recordaba la presencia de lesiones previas en la zona del MM&#59; solo un paciente refiri&#243; que el MM se desarroll&#243; sobre una lesi&#243;n cong&#233;nita&#44; otro sobre una lesi&#243;n que recordaba &#171;de toda la vida&#187; y otro sobre una lesi&#243;n de 10 a&#241;os de evoluci&#243;n &#40;13&#44;4&#37;&#41;&#46; En 5 de los casos se refiri&#243; un traumatismo importante en esa zona a&#241;os antes &#40;21&#44;7&#37;&#41; y ninguno record&#243; haber padecido una quemadura en la zona&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se detalla la localizaci&#243;n exacta del MLA de los 23 pacientes encuestados&#46; En 17 pacientes el MLA se localizaba en el pie &#40;73&#44;9&#37;&#41; y en 6 en la mano &#40;26&#44;1&#37;&#41;&#46; En las manos 4 de 6 casos ten&#237;an localizaci&#243;n subungueal y no hubo predominio de ninguna de las manos&#46; En los pies hubo un predominio de localizaci&#243;n en las zonas de apoyo plantar &#40;12 de 17&#41;&#46; De los que no se localizaban en zona de apoyo&#44; uno se ubicaba en el arco plantar&#44; otro en el dorso del pie&#44; otro en la regi&#243;n subungueal del primer dedo y otro en la regi&#243;n subungueal del cuarto dedo&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">De estos 23 pacientes los signos y s&#237;ntomas m&#225;s habitualmente referidos&#44; por orden de frecuencia&#44; fueron &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#58; un tama&#241;o superior a 6<span class="elsevierStyleHsp" style=""></span>mm en 13 casos &#40;61&#44;9&#37;&#41;&#44; el sangrado en 12 &#40;54&#44;5&#37;&#41;&#44; un cambio de tama&#241;o en 10 &#40;47&#44;6&#37;&#41;&#44; un cambio de forma en 9 &#40;42&#44;9&#37;&#41;&#44; un cambio de color en 8 &#40;38&#44;1&#37;&#41; y la adquisici&#243;n de relieve en 7 &#40;33&#44;3&#37;&#41;&#46; Otros s&#237;ntomas y signos no incluidos en los criterios de ABCD y en los 7 puntos de la escala de Glasgow&#44; y referidos por los pacientes&#44; fueron&#58; una distrofia ungueal en 2 casos&#44; sudoraci&#243;n nocturna desde meses antes en un caso&#44; astenia en un caso y una adenopat&#237;a inguinal en otro caso&#46; De todos estos signos y s&#237;ntomas los que motivaron una consulta m&#233;dica&#44; por orden de frecuencia&#44; fueron&#58; el sangrado en 7 casos &#40;29&#44;2&#37;&#41;&#44; un cambio de color en 5 pacientes &#40;21&#44;7&#37;&#41; y de tama&#241;o en otros 5 &#40;21&#44;7&#37;&#41;&#44; de forma en 2 &#40;8&#44;7&#37;&#41;&#44; la sensaci&#243;n de dolor en otros 2 &#40;8&#44;7&#37;&#41;&#44; la distrofia ungueal tambi&#233;n en 2 casos &#40;8&#44;7&#37;&#41; y en tan solo un caso &#40;4&#44;4&#37;&#41; por la adquisici&#243;n de relieve&#44; la presencia de bordes irregulares o la presencia de adenopat&#237;as inguinales&#44; una adquisici&#243;n de relieve y la observaci&#243;n de bordes irregulares&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">En relaci&#243;n con qui&#233;n detect&#243; la lesi&#243;n&#44; qui&#233;n decidi&#243; que ten&#237;a que ser evaluada por un dermat&#243;logo y cu&#225;l fue el motivo de consulta&#44; en 2 casos &#40;8&#44;7&#37;&#41; el paciente consult&#243; por otra lesi&#243;n a un pod&#243;logo que&#44; a su vez&#44; realiz&#243; el diagn&#243;stico y lo deriv&#243; a un dermat&#243;logo&#46; En 17 casos &#40;73&#44;9&#37;&#41; la lesi&#243;n fue detectada por el propio paciente&#44; pero en 6 de ellos &#40;35&#44;3&#37;&#41; la idea de consultar con un especialista fue de un familiar o de un amigo&#46; En un caso la lesi&#243;n fue detectada por un m&#233;dico de familia al consultar por otro motivo y deriv&#243; al paciente a un dermat&#243;logo&#46; En otro caso la lesi&#243;n fue detectada de forma casual por un dermat&#243;logo al consultar por otra lesi&#243;n&#46; En 4 de los 5 casos en los que el paciente consult&#243; a instancias de otra persona&#44; el familiar o la amistad fue del sexo femenino&#46; En 5 casos &#40;21&#44;7&#37;&#41; el motivo de consulta fue otra lesi&#243;n distinta al MM&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Trece de 17 mujeres se detectaron ellas mismas la lesi&#243;n&#44; 10 &#40;76&#44;9&#37;&#41; decidieron consultar con un especialista y solo en 3 casos &#40;23&#44;1&#37;&#41; la idea de consultar con un especialista fue de otra persona&#46; En el caso de los hombres 4 de 6 se detectaron ellos mismos la lesi&#243;n&#44; solo uno decidi&#243; consultar con un especialista y en 3 casos la idea de consultar con un especialista fue de otra persona&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Tambi&#233;n se recogi&#243; el tiempo que los pacientes tardaron en consultar con personal sanitario y el tiempo que se tard&#243; en realizar una biopsia &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; El primer personal sanitario al que se acudi&#243; fue&#44; por orden de frecuencia&#44; un m&#233;dico de familia &#40;9 casos&#44; 34&#44;8&#37;&#41;&#44; un dermat&#243;logo &#40;8 casos&#44; 39&#44;1&#37;&#41; y un pod&#243;logo &#40;6 casos&#44; 26&#44;1&#37;&#41;&#46; De los pod&#243;logos 4 de 6 &#40;66&#44;7&#37;&#41; sospecharon desde el inicio que se trataba de una lesi&#243;n para biopsiar&#44; de los m&#233;dicos de familia 5 de 10 &#40;50&#37;&#41; y de los dermat&#243;logos 21 de 27 &#40;77&#44;8&#37;&#41;&#46; Durante el proceso evolutivo del paciente se sugiri&#243; que la lesi&#243;n ten&#237;a que ser biopsiada por parte del primer m&#233;dico consultado solo en 13 casos &#40;56&#44;5&#37;&#41;&#44; del segundo en 5 &#40;21&#44;7&#37;&#41; casos&#44; del tercero en un caso &#40;4&#44;4&#37;&#41;&#44; del cuarto en 3 casos &#40;13&#44;0&#37;&#41; y del quinto en un caso &#40;4&#44;4&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">El retraso del paciente fue de menos de un mes en 6 de los 23 casos &#40;26&#44;1&#37;&#41;&#44; de uno a 3 meses en 4 casos &#40;17&#44;4&#37;&#41;&#44; de 3 a 6 meses en otros 3 casos &#40;13&#44;0&#37;&#41;&#44; de 6 meses a un a&#241;o en 3 casos &#40;13&#44;0&#37;&#41; y de m&#225;s de un a&#241;o en 7 de los casos &#40;30&#44;4&#37;&#41;&#46; Por lo tanto&#44; un 43&#44;4&#37; de los pacientes tardaron m&#225;s de 6 meses en consultar&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">El retraso del personal sanitario fue de menos de un mes en 9 de los 23 casos &#40;36&#44;0&#37;&#41;&#44; de uno a 3 meses en 7 casos &#40;28&#44;0&#37;&#41;&#44; de 3 a 6 meses en un caso &#40;4&#44;0&#37;&#41;&#44; de 6 meses a un a&#241;o en 2 casos &#40;8&#44;0&#37;&#41; y de m&#225;s de un a&#241;o en 5 de los 23 casos &#40;20&#44;0&#37;&#41;&#46; Por lo tanto&#44; en casi un tercio de los casos hubo una demora atribuible al personal sanitario de al menos 6 meses&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0135" class="elsevierStylePara elsevierViewall">Antes de valorar los hallazgos del presente estudio descriptivo se deben tener en consideraci&#243;n varias limitaciones&#46; En primer lugar&#44; se trata de un estudio retrospectivo&#44; se basa en encuestas telef&#243;nicas &#40;que se ven limitadas por la memoria del paciente y porque es posible que queden vivos los pacientes de mejor pron&#243;stico&#41; y por &#250;ltimo&#44; el que la muestra sea peque&#241;a&#46; A pesar de todo&#44; aporta datos interesantes sobre el MLA que&#44; en l&#237;neas generales&#44; coinciden con lo descrito en la literatura&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">De los 23 pacientes encuestados la mayor&#237;a tuvieron el melanoma en el pie&#44; pero cuando la afectaci&#243;n era subungueal la mano estaba m&#225;s frecuentemente afectada y el dedo m&#225;s afectado tambi&#233;n era el primero tanto de la mano como del pie&#46; Entre los que ten&#237;an afectaci&#243;n del pie la mayor&#237;a se localizaba en zonas de apoyo&#44; lo que sugiere que la presi&#243;n puede tener alg&#250;n papel etiopatog&#233;nico&#44; quiz&#225;s asociada al calor o a los traumatismos repetidos&#46; El reciente hallazgo de la sobreexpresi&#243;n de NUAK2 en los MLA podr&#237;a apoyar esta teor&#237;a<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Seg&#250;n series previas la extremidad inferior se ve afectada en un 82&#37;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> respecto a la extremidad superior&#44; excepto en el melanoma subungueal&#44; en el que la afectaci&#243;n de la mano es ligeramente superior&#58; 55&#37; respecto a 45&#37;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10&#44;11</span></a>&#46; El melanoma plantar representar&#237;a el 2&#44;8&#37;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> de todos los MM y el MM de la mano del 1 al 2&#37;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#44; y los dedos m&#225;s frecuentemente afectados ser&#237;an&#44; como en nuestro caso&#44; el primero tanto de la mano como del pie&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Aunque&#44; generalmente&#44; en las palmas y las plantas se presentan con relativa frecuencia los signos y s&#237;ntomas de las reglas del ABCDE y de la lista de los 7puntos&#44; existe un importante retraso diagn&#243;stico del MLA debido a su polimorfismo cl&#237;nico&#46; As&#237;&#44; Soon et al&#46; refieren que en su serie de 112 MLA plantares un 33&#44;96&#37; fueron incorrectamente diagnosticados&#59; de estos&#44; hasta un 60&#37; eran amelan&#243;ticos y un 39&#37; simulaban una lesi&#243;n hiperquerat&#243;sica benigna<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">En nuestra serie de los 23 pacientes encuestados el 61&#44;9&#37; refiri&#243; un tama&#241;o superior a 6<span class="elsevierStyleHsp" style=""></span>mm&#44; el 54&#44;5&#37; sangrado&#44; el 47&#44;6&#37; un cambio de tama&#241;o y el 42&#44;9&#37; un cambio en la forma&#46; Sin embargo&#44; en al menos la mitad de los casos&#44; y con la excepci&#243;n del dolor y el sangrado que s&#237; fueron considerados como relevantes&#44; los pacientes no consideraban que los signos y s&#237;ntomas observados eran motivos para consultar a un especialista&#46; En cualquier caso&#44; el sangrado&#44; los cambios de coloraci&#243;n y de tama&#241;o fueron los principales motivos por los que los pacientes consultaron&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En nuestro estudio llama la atenci&#243;n que solo un 39&#44;1&#37; de los pacientes hab&#237;a consultado en primer lugar a un dermat&#243;logo&#44; un 37&#44;8&#37; de los casos a un m&#233;dico de familia y a un pod&#243;logo en un 26&#44;1&#37;&#46; La sospecha de lesi&#243;n maligna fue&#44; como era de esperar&#44; mayor entre los dermat&#243;logos &#40;77&#44;8&#37;&#41; y menor en los pod&#243;logos &#40;66&#44;7&#37;&#41; y los m&#233;dicos de familia &#40;50&#37;&#41;&#46; Este hallazgo subraya el papel que pueden tener algunos profesionales de la salud&#44; en particular los pod&#243;logos&#44; en la detecci&#243;n precoz de lesiones acrales&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">En nuestra serie observamos un importante retraso diagn&#243;stico tanto por parte del paciente &#40;un 52&#44;2&#37; tarda m&#225;s de 3 meses en consultar y un 34&#44;8&#37; por lo menos un a&#241;o&#41; como por parte del m&#233;dico &#40;solo en un 56&#44;5&#37; de los casos se sospech&#243; en la primera consulta que la lesi&#243;n deb&#237;a ser biopsiada y hasta en un 56&#44;5&#37; se tard&#243; m&#225;s de 3 meses en realizar una biopsia&#41;&#46; En su serie&#44; Richard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> encuentran que un 14&#44;2&#37; de los m&#233;dicos no propusieron la ex&#233;resis en la primera consulta y que los retrasos eran mayores en presentaciones at&#237;picas&#44; como los MM amelan&#243;ticos&#44; cuando no exist&#237;a un nevus anterior y en el MLA&#46; Este porcentaje es bastante menor que en nuestra serie&#44; que es del 43&#44;5&#37; en general y del 22&#44;2&#37; entre los dermat&#243;logos&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Cabe destacar que aunque el porcentaje de detecci&#243;n de la lesi&#243;n por el paciente fue alta &#40;73&#44;9&#37;&#41;&#44; hasta en un 35&#44;3&#37; de estos casos la idea de consultar con un especialista fue de un familiar o de una amiga&#44; y que existe un predominio del sexo femenino a la hora de consultar tanto entre los pacientes como entre los familiares&#44; datos que son acordes con los de la literatura&#46; En los trabajos de Richard et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> se constata que en dos tercios de los casos el MM es detectado o por el paciente o por un familiar&#44; y que este &#250;ltimo era responsable de la detecci&#243;n de la lesi&#243;n y de acelerar la visita al m&#233;dico hasta en la mitad de los casos&#46; Al igual que en nuestra serie&#44; las mujeres detectan el MM con mayor frecuencia que los hombres&#44; en los que la necesidad de consulta era sugerida generalmente por un familiar o por un m&#233;dico&#46; La mediana de tiempo transcurrido entre que el paciente se percat&#243; de la lesi&#243;n y que sospech&#243; su probable malignidad fue de 25 meses&#44; y desde que tuvo dicha sospecha hasta que decidi&#243; consultar a un m&#233;dico la mediana fue de 2 meses&#46; Cabe destacar que&#44; en dicho estudio&#44; pese a las campa&#241;as preventivas&#44; un 25&#37; de los pacientes pensaban que quitar una lesi&#243;n melanoc&#237;tica era peligroso&#44; solo un 24&#44;8&#37; de los pacientes eran conscientes de la gravedad de un melanoma&#44; y otros segu&#237;an creyendo que no pod&#237;a existir un c&#225;ncer si no hab&#237;a sangrado&#44; dolor o astenia&#46; Los signos y s&#237;ntomas que motivaban una consulta r&#225;pida a un profesional sanitario eran los signos y s&#237;ntomas tard&#237;os como el sangrado&#44; mientras que los signos del ABCD motivaban una demora en la consulta&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; existe un importante retraso diagn&#243;stico tanto por parte del paciente como del personal sanitario&#46; Estos datos nos sugieren que existen fallos en las campa&#241;as de prevenci&#243;n del MM&#58; la poblaci&#243;n no conoce todav&#237;a correctamente las reglas del ABCD ni de los 7 puntos de Glasgow&#44; desconoce las zonas acrales como posible localizaci&#243;n del MM&#44; no se informa de la cl&#237;nica del MM subungueal&#44; se deber&#237;a instruir m&#225;s a los m&#233;dicos de familia y a los pod&#243;logos sobre este melanoma y se deber&#237;a hacer un mayor &#233;nfasis en varones&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Responsabilidades &#233;ticas</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protecci&#243;n de personas y animales</span><p id="par0175" class="elsevierStylePara elsevierViewall">Los autores declaran que para esta investigaci&#243;n no se han realizado experimentos en seres humanos ni en animales&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidencialidad de los datos</span><p id="par0180" class="elsevierStylePara elsevierViewall">Los autores declaran que han seguido los protocolos de su centro de trabajo sobre la publicaci&#243;n de datos de pacientes y que todos los pacientes incluidos en el estudio han recibido informaci&#243;n suficiente y han dado su consentimiento informado por escrito para participar en dicho estudio&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Derecho a la privacidad y consentimiento informado</span><p id="par0185" class="elsevierStylePara elsevierViewall">Los autores declaran que en este art&#237;culo no aparecen datos de pacientes&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicto de intereses</span><p id="par0190" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => array:5 [
            0 => "Abstract"
            1 => "Background and objective"
            2 => "Materials and methods"
            3 => "Results"
            4 => "Conclusions"
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        3 => array:2 [
          "identificador" => "xpalclavsec83559"
          "titulo" => "Keywords"
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        4 => array:2 [
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          "titulo" => "Introducci&#243;n"
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          "titulo" => "Pacientes y m&#233;todos"
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          "titulo" => "Resultados"
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          "titulo" => "Discusi&#243;n"
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          "titulo" => "Responsabilidades &#233;ticas"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Protecci&#243;n de personas y animales"
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Confidencialidad de los datos"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Derecho a la privacidad y consentimiento informado"
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          ]
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        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflicto de intereses"
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        10 => array:1 [
          "titulo" => "Bibliograf&#237;a"
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      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2012-02-29"
    "fechaAceptado" => "2012-06-21"
    "PalabrasClave" => array:2 [
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec83558"
          "palabras" => array:5 [
            0 => "Melanoma lentiginoso acral"
            1 => "Retraso diagn&#243;stico"
            2 => "S&#237;ntomas"
            3 => "Signos"
            4 => "Epidemiolog&#237;a"
          ]
        ]
      ]
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec83559"
          "palabras" => array:5 [
            0 => "Acral lentiginous melanoma"
            1 => "Diagnostic delay"
            2 => "Symptoms"
            3 => "Signs"
            4 => "Epidemiology"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">El melanoma lentiginoso acral &#40;MLA&#41; es el tipo de melanoma de localizaci&#243;n acral m&#225;s frecuente y suele diagnosticarse en estadios m&#225;s avanzados que el resto de los tipos de melanoma&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El objetivo de nuestro estudio fue conocer las caracter&#237;sticas de presentaci&#243;n cl&#237;nica del MLA&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio descriptivo observacional restrospectivo a partir de los pacientes recogidos en la base de datos del Instituto Valenciano de Oncolog&#237;a &#40;IVO&#41;&#46; Mediante encuestas telef&#243;nicas a los pacientes se recogieron las caracter&#237;sticas de presentaci&#243;n de la lesi&#243;n&#44; en particular la presencia de los signos y s&#237;ntomas incluidos en las reglas del ABCDE y de los 7 puntos de Glasgow&#44; as&#237; como el retraso en el diagn&#243;stico atribuible al paciente o al m&#233;dico&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En una muestra final de 23 pacientes que pudieron responder finalmente a la encuesta se constat&#243; que el diagn&#243;stico se demor&#243; m&#225;s de un a&#241;o por un retraso en la consulta por parte del paciente en un 30&#44;4&#37;&#46; Por otra parte&#44; hubo una demora de m&#225;s de un a&#241;o atribuible al m&#233;dico que no sospech&#243; el diagn&#243;stico en un 20&#37; de los casos&#46; Respecto a los motivos m&#225;s frecuentes de consulta estos fueron&#58; cambios en el tama&#241;o&#44; en el color&#44; sangrado y herida que no cura&#46; En un 20&#37; de los casos que fueron evaluados por un m&#233;dico la decisi&#243;n de realizar el estudio histol&#243;gico se demor&#243; m&#225;s de un a&#241;o&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Existe un importante retraso en el diagn&#243;stico del MLA debido tanto al paciente como al m&#233;dico&#44; lo que es achacable en parte a una falta de reconocimiento de los signos de alarma en lo que concierne al paciente y al personal sanitario&#46; Las campa&#241;as preventivas del melanoma deber&#237;an poner m&#225;s &#233;nfasis en la posible afectaci&#243;n de las palmas y sobre todo de las plantas&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Background and objective</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Acral lentiginous melanomas &#8212;the melanomas most commonly found on the distal portions of the limbs&#8212; have usually reached more advanced stages than other types of melanoma when diagnosed&#46; Our aim was to describe the clinical presentation of these tumors&#46;</p> <span class="elsevierStyleSectionTitle">Materials and methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Retrospective&#44; descriptive&#44; observational study of cases recorded in the database of the Instituto Valenciano de Oncolog&#237;a&#46; In telephone interviews the patients answered a questionnaire on the presenting features of the lesion&#44; on the presence of signs and symptoms included in the Glasgow 7-point checklist and the ABCDEs of melanoma&#44; and on diagnostic delay attributable to patient or physician&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">In the interviews with the 23 patients who responded to the questionnaire&#44; we detected a diagnostic delay of more than 1 year attributable to the patient &#40;delay in seeking care&#41; in 30&#46;4&#37; of the cases&#46; Diagnostic delay of more than 1 year attributable to the physician &#40;failure to suspect the diagnosis&#41; was identified in 20&#37;&#46; The most frequent reasons for consulting a physician about a lesion were changes in size&#44; changes in color&#44; bleeding&#44; or failure to heal&#46; In 20&#37; of the cases the evaluating physician did not order histology for over a year&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagnostic delay is a significant problem in acral lentiginous melanoma and may be attributable either to patients or to physicians&#8217; failure to recognize warning signs&#46; Melanoma prevention campaigns should place more emphasis on the possibility of melanomas appearing on the palms and&#44; particularly&#44; on the soles&#46;</p>"
      ]
    ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">D&#58; dorso&#59; Dch&#58; derecho&#59; Iz&#58; izquierdo&#59; Pa&#58; palma&#59; Pl&#58; planta&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Mano</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="6" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Pie</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Dedo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Subungueal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Iz&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Dch&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Pa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Iz&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Dch&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Pl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Zona apoyo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Arco plantar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Anterior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Anterior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tal&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tal&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tal&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab182462.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Localizaci&#243;n de la lesi&#243;n</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Tabla 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "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"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Caracter&#237;sticas de la lesi&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Signos y s&#237;ntomas&nbsp;\t\t\t\t\t\t\n
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                  \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">Porcentaje&nbsp;\t\t\t\t\t\t\n
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                  \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">Motivo de consulta&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Porcentaje respecto al total de MM &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Porcentaje respecto al total de pacientes sintom&#225;ticos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">N&#250;mero&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">N&#250;mero&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Asimetr&#237;a</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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">Bordes irregulares</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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">&#8805;<span class="elsevierStyleHsp" style=""></span>2 colores</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Sudoraci&#243;n nocturna</span>&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Var&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;Hemangioma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Mujer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46; Hematoma4&#46; Verruga&nbsp;\t\t\t\t\t\t\n
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              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">Los n&#250;meros en cada personal sanitario se corresponden con el orden con el que el especialista evalu&#243; la lesi&#243;n y el diagn&#243;stico de sospecha realizado&#46;</p>"
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              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara">El cirujano lo remite a enfermer&#237;a para curas&#46;</p>"
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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Personal sanitario consultado&#44; retraso diagn&#243;stico y Breslow de los 23 pacientes encuestados<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous melanoma"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;F&#46; Thompson"
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                0 => array:2 [
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                      "titulo" => "The National Cancer Data Base report on cutaneous and noncutaneous melanoma&#58; a summary of 84&#44;836 cases from the past decade&#46; The American College of Surgeons Commission on Cancer and the American Cancer Society"
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                      "titulo" => "Acral cutaneous melanoma in caucasians&#58; clinical features&#44; histopathology and prognosis in 112 patients"
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Original
Estudio descriptivo de la presentación clínica del melanoma lentiginoso acral
Clinical Presentation of Acral Lentiginous Melanoma: A Descriptive Study
C. Peredaa, V. Travesb, C. Requenaa, C. Serra-Guilléna, B. Llombarta, O. Sanmartína, C. Guilléna, E. Nagorea,
Autor para correspondencia
eduyame@meditex.es

Autor para correspondencia.
a Servicio de Dermatología, Fundación Instituto Valenciano de Oncología,Valencia, España
b Servicio de Anatomía Patológica, Fundación Instituto Valenciano de Oncología, Valencia, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">El melanoma cut&#225;neo es un importante problema de salud&#46; Desde mediados de los a&#241;os 60 la incidencia del melanoma &#40;MM&#41; se ha incrementado de un 3 a un 8&#37; por a&#241;o en Europa&#44; y por cada muerte por melanoma en los EE&#46;UU&#46; se estima que se pierde una media de 18&#44;6 a&#241;os de vida potencial<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Existen 4 subtipos principales de melanomas&#58; el melanoma de extensi&#243;n superficial &#40;MES&#41;&#44; el melanoma sobre lentigo maligno &#40;MLM&#41;&#44; el melanoma nodular &#40;MN&#41; y el melanoma lentiginoso acral &#40;MLA&#41;&#46; Seg&#250;n algunos autores el 7&#37; de todos los melanomas cut&#225;neos se localizan en zonas acrales<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; Como es bien sabido&#44; todos los tipos de MM se pueden encontrar en las zonas acrales&#44; pero el subtipo m&#225;s prevalente es el MLA&#46; Dicho subtipo aparece en el dorso de las manos y de los pies&#44; en las palmas&#44; en las plantas&#44; en las mu&#241;ecas&#44; en los tobillos y en la regi&#243;n subungueal<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Aunque la incidencia del MLA parece ser similar entre las distintas razas&#44; se constata una mayor proporci&#243;n en las no cauc&#225;sicas&#44; que parece deberse a una incidencia menor del resto de MM<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La edad media de inicio del MLA es superior a la del resto de MM&#58; 59-63 a&#241;os en publicaciones previas con un pico de incidencia durante la s&#233;ptima d&#233;cada<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El MLA&#44; al igual que ocurre con el MN&#44; se diagnostica con menor frecuencia en estadios precoces respecto al MLM y al MES&#46; Este hecho podr&#237;a ser explicado por varias hip&#243;tesis no excluyentes entre s&#237;&#44; un comportamiento biol&#243;gico m&#225;s agresivo que otros tipos de MM&#44; una falta de conciencia en la poblaci&#243;n de la posibilidad de que el melanoma se presente en las regiones subungueales o palmo-plantares&#44; una presentaci&#243;n cl&#237;nica distinta a la de otros MM en otras localizaciones o la dificultad para detectar las lesiones por estar ocultas a la vista durante la vida cotidiana o por una menor atenci&#243;n hacia la salud debido al grupo de edad en el que se presenta&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">El m&#233;todo ABCDE &#40;Asimetr&#237;a&#44; Bordes irregulares&#44; cambio de Color&#44; Di&#225;metro superior a 6<span class="elsevierStyleHsp" style=""></span>mm&#44; Evoluci&#243;n&#41;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> y la lista de los 7 puntos de Glasgow &#40;cambio en tama&#241;o&#44; forma o color&#44; di&#225;metro superior a 6<span class="elsevierStyleHsp" style=""></span>mm&#44; inflamaci&#243;n&#44; exudaci&#243;n o sangrado&#44; leve prurito o cambios de sensibilidad&#41; son los 2 m&#233;todos propuestos para la detecci&#243;n de MM en estadios precoces&#46; Dada la localizaci&#243;n poco accesible&#44; y a que esta variedad es menos conocida entre la poblaci&#243;n general&#44; dado que su presentaci&#243;n podr&#237;a no ser la caracter&#237;stica del melanoma en otras localizaciones&#44; es posible que los MLA sean detectados de forma tard&#237;a&#44; tanto por el paciente como por el personal sanitario&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El objetivo del presente estudio es la descripci&#243;n de la presentaci&#243;n cl&#237;nica del MLA&#44; el patr&#243;n de detecci&#243;n y la prevalencia de los signos y s&#237;ntomas descritos en la regla del ABCDE y la lista de los 7puntos de Glasgow&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="par0040" class="elsevierStylePara elsevierViewall">Realizamos un estudio observacional retrospectivo con la base de datos de melanomas cut&#225;neos del Instituto Valenciano de Oncolog&#237;a &#40;IVO&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Se realiz&#243; un cuestionario telef&#243;nico a los pacientes con MLA sobre sus datos epidemiol&#243;gicos y la cl&#237;nica de la lesi&#243;n&#46; La descripci&#243;n de dicha lesi&#243;n fue comparada&#44; posteriormente&#44; con fotos preoperatorias en los casos en los que la imagen estuviera disponible&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se seleccionaron aquellos pacientes diagnosticados de MLA y tratados de forma definitiva en el Servicio de Dermatolog&#237;a del IVO desde enero de 1999 hasta diciembre de 2006&#46; Se incluyeron los pacientes vivos y capaces de responder a la entrevista telef&#243;nica&#46; La entrevista fue realizada durante los primeros 6 meses del a&#241;o 2007&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Para cada paciente se recogieron los siguientes datos&#58; el sexo&#44; la edad al inicio de la cl&#237;nica&#44; la edad en el momento de la extirpaci&#243;n y el nivel de estudios &#40;categorizado seg&#250;n la edad hasta la que curs&#243; estudios el paciente &#8804;<span class="elsevierStyleHsp" style=""></span>14&#44; &#8804;<span class="elsevierStyleHsp" style=""></span>18&#44; &#8804;<span class="elsevierStyleHsp" style=""></span>21&#44; &#62;<span class="elsevierStyleHsp" style=""></span>21&#44; y que puede equivaler a sin estudios&#44; estudios elementales&#44; medios o superiores&#44; respectivamente&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">En cuanto a las caracter&#237;sticas del MLA se estudiaron los antecedentes de la lesi&#243;n&#44; el motivo de consulta&#44; el retraso diagn&#243;stico y los signos y s&#237;ntomas&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><p id="par0060" class="elsevierStylePara elsevierViewall">Para los antecedentes de la lesi&#243;n se tuvo en cuenta la localizaci&#243;n&#44; si exist&#237;a una lesi&#243;n previa &#40;ninguna&#47;cong&#233;nita&#47;&#171;de toda la vida&#187;&#47;a&#241;os&#41;&#44; antecedente de traumatismos o de quemaduras &#40;ninguno&#47;leve&#47;intenso&#41; en esa localizaci&#243;n&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><p id="par0065" class="elsevierStylePara elsevierViewall">Los datos relacionados con el motivo de consulta fueron&#58; primera persona que se percat&#243; de la lesi&#243;n &#40;paciente&#47;m&#233;dico&#47;otra persona&#41;&#44; si la lesi&#243;n fue el motivo de consulta&#44; de qui&#233;n fue la idea de consultar&#44; n&#250;mero y especialidad del personal sanitario consultado y los diagn&#243;sticos previos&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><p id="par0070" class="elsevierStylePara elsevierViewall">El retraso del paciente se defini&#243; como el tiempo transcurrido entre la primera vez que se percat&#243; de la existencia de la lesi&#243;n y el momento de la consulta&#46; El retraso del m&#233;dico se defini&#243; como el tiempo transcurrido entre la primera consulta con el personal sanitario y la biopsia&#46; Ambos retrasos se clasificaron en los siguientes intervalos de tiempo&#58; &#8804;<span class="elsevierStyleHsp" style=""></span>1 mes&#44; &#62;<span class="elsevierStyleHsp" style=""></span>1 mes a &#8804;<span class="elsevierStyleHsp" style=""></span>3 meses&#44; entre &#62;<span class="elsevierStyleHsp" style=""></span>3 meses a &#8804;<span class="elsevierStyleHsp" style=""></span>6 meses&#44; entre &#62;<span class="elsevierStyleHsp" style=""></span>6 meses a &#8804;<span class="elsevierStyleHsp" style=""></span>1 a&#241;o y m&#225;s de un a&#241;o&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><p id="par0075" class="elsevierStylePara elsevierViewall">Tambi&#233;n se recogieron mediante la encuesta telef&#243;nica los signos y los s&#237;ntomas incluidos en el ABCD y en la lista de los 7 puntos de Glasgow con los que se present&#243; la lesi&#243;n&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><p id="par0080" class="elsevierStylePara elsevierViewall">Desde enero de 1999 hasta diciembre de 2006 1&#46;017 pacientes&#44; todos ellos cauc&#225;sicos&#44; fueron controlados por un melanoma cut&#225;neo en el Servicio de Dermatolog&#237;a del IVO&#46; Ochenta y cinco &#40;8&#44;36&#37;&#41; presentaban un melanoma de localizaci&#243;n acral y&#44; de ellos&#44; 46 un MLA &#40;4&#44;52&#37; del total de MM y 54&#44;1&#37; de los melanomas acrales&#41;&#44; los restantes fueron 23 melanomas de extensi&#243;n superficial&#44; 15 melanomas nodulares y un lentigo maligno melanoma&#46; De los 46 pacientes con MLA solo quedaban vivos 34&#46; De estos 34 no se pudo contactar con 8 y 3 no pudieron realizar el cuestionario telef&#243;nico &#40;uno por un infarto cerebral&#44; otro por demencia y otro por efectos secundarios del interfer&#243;n&#41;&#46; 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En los pies hubo un predominio de localizaci&#243;n en las zonas de apoyo plantar &#40;12 de 17&#41;&#46; De los que no se localizaban en zona de apoyo&#44; uno se ubicaba en el arco plantar&#44; otro en el dorso del pie&#44; otro en la regi&#243;n subungueal del primer dedo y otro en la regi&#243;n subungueal del cuarto dedo&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">De estos 23 pacientes los signos y s&#237;ntomas m&#225;s habitualmente referidos&#44; por orden de frecuencia&#44; fueron &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#58; un tama&#241;o superior a 6<span class="elsevierStyleHsp" style=""></span>mm en 13 casos &#40;61&#44;9&#37;&#41;&#44; el sangrado en 12 &#40;54&#44;5&#37;&#41;&#44; un cambio de tama&#241;o en 10 &#40;47&#44;6&#37;&#41;&#44; un cambio de forma en 9 &#40;42&#44;9&#37;&#41;&#44; un cambio de color en 8 &#40;38&#44;1&#37;&#41; y la adquisici&#243;n de relieve en 7 &#40;33&#44;3&#37;&#41;&#46; 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la lesi&#243;n&#44; qui&#233;n decidi&#243; que ten&#237;a que ser evaluada por un dermat&#243;logo y cu&#225;l fue el motivo de consulta&#44; en 2 casos &#40;8&#44;7&#37;&#41; el paciente consult&#243; por otra lesi&#243;n a un pod&#243;logo que&#44; a su vez&#44; realiz&#243; el diagn&#243;stico y lo deriv&#243; a un dermat&#243;logo&#46; En 17 casos &#40;73&#44;9&#37;&#41; la lesi&#243;n fue detectada por el propio paciente&#44; pero en 6 de ellos &#40;35&#44;3&#37;&#41; la idea de consultar con un especialista fue de un familiar o de un amigo&#46; En un caso la lesi&#243;n fue detectada por un m&#233;dico de familia al consultar por otro motivo y deriv&#243; al paciente a un dermat&#243;logo&#46; En otro caso la lesi&#243;n fue detectada de forma casual por un dermat&#243;logo al consultar por otra lesi&#243;n&#46; En 4 de los 5 casos en los que el paciente consult&#243; a instancias de otra persona&#44; el familiar o la amistad fue del sexo femenino&#46; En 5 casos &#40;21&#44;7&#37;&#41; el motivo de consulta fue otra lesi&#243;n distinta al MM&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Trece de 17 mujeres se detectaron ellas mismas la lesi&#243;n&#44; 10 &#40;76&#44;9&#37;&#41; decidieron consultar con un especialista y solo en 3 casos &#40;23&#44;1&#37;&#41; la idea de consultar con un especialista fue de otra persona&#46; En el caso de los hombres 4 de 6 se detectaron ellos mismos la lesi&#243;n&#44; solo uno decidi&#243; consultar con un especialista y en 3 casos la idea de consultar con un especialista fue de otra persona&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Tambi&#233;n se recogi&#243; el tiempo que los pacientes tardaron en consultar con personal sanitario y el tiempo que se tard&#243; en realizar una biopsia &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; El primer personal sanitario al que se acudi&#243; fue&#44; por orden de frecuencia&#44; un m&#233;dico de familia &#40;9 casos&#44; 34&#44;8&#37;&#41;&#44; un dermat&#243;logo &#40;8 casos&#44; 39&#44;1&#37;&#41; y un pod&#243;logo &#40;6 casos&#44; 26&#44;1&#37;&#41;&#46; De los pod&#243;logos 4 de 6 &#40;66&#44;7&#37;&#41; sospecharon desde el inicio que se trataba de una lesi&#243;n para biopsiar&#44; de los m&#233;dicos de familia 5 de 10 &#40;50&#37;&#41; y de los dermat&#243;logos 21 de 27 &#40;77&#44;8&#37;&#41;&#46; Durante el proceso evolutivo del paciente se sugiri&#243; que la lesi&#243;n ten&#237;a que ser biopsiada por parte del primer m&#233;dico consultado solo en 13 casos &#40;56&#44;5&#37;&#41;&#44; del segundo en 5 &#40;21&#44;7&#37;&#41; casos&#44; del tercero en un caso &#40;4&#44;4&#37;&#41;&#44; del cuarto en 3 casos &#40;13&#44;0&#37;&#41; y del quinto en un caso &#40;4&#44;4&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">El retraso del paciente fue de menos de un mes en 6 de los 23 casos &#40;26&#44;1&#37;&#41;&#44; de uno a 3 meses en 4 casos &#40;17&#44;4&#37;&#41;&#44; de 3 a 6 meses en otros 3 casos &#40;13&#44;0&#37;&#41;&#44; de 6 meses a un a&#241;o en 3 casos &#40;13&#44;0&#37;&#41; y de m&#225;s de un a&#241;o en 7 de los casos &#40;30&#44;4&#37;&#41;&#46; Por lo tanto&#44; un 43&#44;4&#37; de los pacientes tardaron m&#225;s de 6 meses en consultar&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">El retraso del personal sanitario fue de menos de un mes en 9 de los 23 casos &#40;36&#44;0&#37;&#41;&#44; de uno a 3 meses en 7 casos &#40;28&#44;0&#37;&#41;&#44; de 3 a 6 meses en un caso &#40;4&#44;0&#37;&#41;&#44; de 6 meses a un a&#241;o en 2 casos &#40;8&#44;0&#37;&#41; y de m&#225;s de un a&#241;o en 5 de los 23 casos &#40;20&#44;0&#37;&#41;&#46; Por lo tanto&#44; en casi un tercio de los casos hubo una demora atribuible al personal sanitario de al menos 6 meses&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0135" class="elsevierStylePara elsevierViewall">Antes de valorar los hallazgos del presente estudio descriptivo se deben tener en consideraci&#243;n varias limitaciones&#46; En primer lugar&#44; se trata de un estudio retrospectivo&#44; se basa en encuestas telef&#243;nicas &#40;que se ven limitadas por la memoria del paciente y porque es posible que queden vivos los pacientes de mejor pron&#243;stico&#41; y por &#250;ltimo&#44; el que la muestra sea peque&#241;a&#46; A pesar de todo&#44; aporta datos interesantes sobre el MLA que&#44; en l&#237;neas generales&#44; coinciden con lo descrito en la literatura&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">De los 23 pacientes encuestados la mayor&#237;a tuvieron el melanoma en el pie&#44; pero cuando la afectaci&#243;n era subungueal la mano estaba m&#225;s frecuentemente afectada y el dedo m&#225;s afectado tambi&#233;n era el primero tanto de la mano como del pie&#46; Entre los que ten&#237;an afectaci&#243;n del pie la mayor&#237;a se localizaba en zonas de apoyo&#44; lo que sugiere que la presi&#243;n puede tener alg&#250;n papel etiopatog&#233;nico&#44; quiz&#225;s asociada al calor o a los traumatismos repetidos&#46; El reciente hallazgo de la sobreexpresi&#243;n de NUAK2 en los MLA podr&#237;a apoyar esta teor&#237;a<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Seg&#250;n series previas la extremidad inferior se ve afectada en un 82&#37;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> respecto a la extremidad superior&#44; excepto en el melanoma subungueal&#44; en el que la afectaci&#243;n de la mano es ligeramente superior&#58; 55&#37; respecto a 45&#37;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10&#44;11</span></a>&#46; El melanoma plantar representar&#237;a el 2&#44;8&#37;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> de todos los MM y el MM de la mano del 1 al 2&#37;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#44; y los dedos m&#225;s frecuentemente afectados ser&#237;an&#44; como en nuestro caso&#44; el primero tanto de la mano como del pie&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Aunque&#44; generalmente&#44; en las palmas y las plantas se presentan con relativa frecuencia los signos y s&#237;ntomas de las reglas del ABCDE y de la lista de los 7puntos&#44; existe un importante retraso diagn&#243;stico del MLA debido a su polimorfismo cl&#237;nico&#46; As&#237;&#44; Soon et al&#46; refieren que en su serie de 112 MLA plantares un 33&#44;96&#37; fueron incorrectamente diagnosticados&#59; de estos&#44; hasta un 60&#37; eran amelan&#243;ticos y un 39&#37; simulaban una lesi&#243;n hiperquerat&#243;sica benigna<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">En nuestra serie de los 23 pacientes encuestados el 61&#44;9&#37; refiri&#243; un tama&#241;o superior a 6<span class="elsevierStyleHsp" style=""></span>mm&#44; el 54&#44;5&#37; sangrado&#44; el 47&#44;6&#37; un cambio de tama&#241;o y el 42&#44;9&#37; un cambio en la forma&#46; Sin embargo&#44; en al menos la mitad de los casos&#44; y con la excepci&#243;n del dolor y el sangrado que s&#237; fueron considerados como relevantes&#44; los pacientes no consideraban que los signos y s&#237;ntomas observados eran motivos para consultar a un especialista&#46; En cualquier caso&#44; el sangrado&#44; los cambios de coloraci&#243;n y de tama&#241;o fueron los principales motivos por los que los pacientes consultaron&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En nuestro estudio llama la atenci&#243;n que solo un 39&#44;1&#37; de los pacientes hab&#237;a consultado en primer lugar a un dermat&#243;logo&#44; un 37&#44;8&#37; de los casos a un m&#233;dico de familia y a un pod&#243;logo en un 26&#44;1&#37;&#46; La sospecha de lesi&#243;n maligna fue&#44; como era de esperar&#44; mayor entre los dermat&#243;logos &#40;77&#44;8&#37;&#41; y menor en los pod&#243;logos &#40;66&#44;7&#37;&#41; y los m&#233;dicos de familia &#40;50&#37;&#41;&#46; Este hallazgo subraya el papel que pueden tener algunos profesionales de la salud&#44; en particular los pod&#243;logos&#44; en la detecci&#243;n precoz de lesiones acrales&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">En nuestra serie observamos un importante retraso diagn&#243;stico tanto por parte del paciente &#40;un 52&#44;2&#37; tarda m&#225;s de 3 meses en consultar y un 34&#44;8&#37; por lo menos un a&#241;o&#41; como por parte del m&#233;dico &#40;solo en un 56&#44;5&#37; de los casos se sospech&#243; en la primera consulta que la lesi&#243;n deb&#237;a ser biopsiada y hasta en un 56&#44;5&#37; se tard&#243; m&#225;s de 3 meses en realizar una biopsia&#41;&#46; En su serie&#44; Richard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> encuentran que un 14&#44;2&#37; de los m&#233;dicos no propusieron la ex&#233;resis en la primera consulta y que los retrasos eran mayores en presentaciones at&#237;picas&#44; como los MM amelan&#243;ticos&#44; cuando no exist&#237;a un nevus anterior y en el MLA&#46; Este porcentaje es bastante menor que en nuestra serie&#44; que es del 43&#44;5&#37; en general y del 22&#44;2&#37; entre los dermat&#243;logos&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Cabe destacar que aunque el porcentaje de detecci&#243;n de la lesi&#243;n por el paciente fue alta &#40;73&#44;9&#37;&#41;&#44; hasta en un 35&#44;3&#37; de estos casos la idea de consultar con un especialista fue de un familiar o de una amiga&#44; y que existe un predominio del sexo femenino a la hora de consultar tanto entre los pacientes como entre los familiares&#44; datos que son acordes con los de la literatura&#46; En los trabajos de Richard et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> se constata que en dos tercios de los casos el MM es detectado o por el paciente o por un familiar&#44; y que este &#250;ltimo era responsable de la detecci&#243;n de la lesi&#243;n y de acelerar la visita al m&#233;dico hasta en la mitad de los casos&#46; Al igual que en nuestra serie&#44; las mujeres detectan el MM con mayor frecuencia que los hombres&#44; en los que la necesidad de consulta era sugerida generalmente por un familiar o por un m&#233;dico&#46; La mediana de tiempo transcurrido entre que el paciente se percat&#243; de la lesi&#243;n y que sospech&#243; su probable malignidad fue de 25 meses&#44; y desde que tuvo dicha sospecha hasta que decidi&#243; consultar a un m&#233;dico la mediana fue de 2 meses&#46; Cabe destacar que&#44; en dicho estudio&#44; pese a las campa&#241;as preventivas&#44; un 25&#37; de los pacientes pensaban que quitar una lesi&#243;n melanoc&#237;tica era peligroso&#44; solo un 24&#44;8&#37; de los pacientes eran conscientes de la gravedad de un melanoma&#44; y otros segu&#237;an creyendo que no pod&#237;a existir un c&#225;ncer si no hab&#237;a sangrado&#44; dolor o astenia&#46; Los signos y s&#237;ntomas que motivaban una consulta r&#225;pida a un profesional sanitario eran los signos y s&#237;ntomas tard&#237;os como el sangrado&#44; mientras que los signos del ABCD motivaban una demora en la consulta&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; existe un importante retraso diagn&#243;stico tanto por parte del paciente como del personal sanitario&#46; Estos datos nos sugieren que existen fallos en las campa&#241;as de prevenci&#243;n del MM&#58; la poblaci&#243;n no conoce todav&#237;a correctamente las reglas del ABCD ni de los 7 puntos de Glasgow&#44; desconoce las zonas acrales como posible localizaci&#243;n del MM&#44; no se informa de la cl&#237;nica del MM subungueal&#44; se deber&#237;a instruir m&#225;s a los m&#233;dicos de familia y a los pod&#243;logos sobre este melanoma y se deber&#237;a hacer un mayor &#233;nfasis en varones&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Responsabilidades &#233;ticas</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protecci&#243;n de personas y animales</span><p id="par0175" class="elsevierStylePara elsevierViewall">Los autores declaran que para esta investigaci&#243;n no se han realizado experimentos en seres humanos ni en animales&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidencialidad de los datos</span><p id="par0180" class="elsevierStylePara elsevierViewall">Los autores declaran que han seguido los protocolos de su centro de trabajo sobre la publicaci&#243;n de datos de pacientes y que todos los pacientes incluidos en el estudio han recibido informaci&#243;n suficiente y han dado su consentimiento informado por escrito para participar en dicho estudio&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Derecho a la privacidad y consentimiento informado</span><p id="par0185" class="elsevierStylePara elsevierViewall">Los autores declaran que en este art&#237;culo no aparecen datos de pacientes&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicto de intereses</span><p id="par0190" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => array:5 [
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            1 => "Background and objective"
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          "titulo" => "Introducci&#243;n"
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          "titulo" => "Pacientes y m&#233;todos"
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          "titulo" => "Resultados"
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          "titulo" => "Responsabilidades &#233;ticas"
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              "titulo" => "Protecci&#243;n de personas y animales"
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              "identificador" => "sec0035"
              "titulo" => "Confidencialidad de los datos"
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            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Derecho a la privacidad y consentimiento informado"
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        9 => array:2 [
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          "titulo" => "Conflicto de intereses"
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        10 => array:1 [
          "titulo" => "Bibliograf&#237;a"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2012-02-29"
    "fechaAceptado" => "2012-06-21"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec83558"
          "palabras" => array:5 [
            0 => "Melanoma lentiginoso acral"
            1 => "Retraso diagn&#243;stico"
            2 => "S&#237;ntomas"
            3 => "Signos"
            4 => "Epidemiolog&#237;a"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec83559"
          "palabras" => array:5 [
            0 => "Acral lentiginous melanoma"
            1 => "Diagnostic delay"
            2 => "Symptoms"
            3 => "Signs"
            4 => "Epidemiology"
          ]
        ]
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    "resumen" => array:2 [
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">El melanoma lentiginoso acral &#40;MLA&#41; es el tipo de melanoma de localizaci&#243;n acral m&#225;s frecuente y suele diagnosticarse en estadios m&#225;s avanzados que el resto de los tipos de melanoma&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El objetivo de nuestro estudio fue conocer las caracter&#237;sticas de presentaci&#243;n cl&#237;nica del MLA&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio descriptivo observacional restrospectivo a partir de los pacientes recogidos en la base de datos del Instituto Valenciano de Oncolog&#237;a &#40;IVO&#41;&#46; Mediante encuestas telef&#243;nicas a los pacientes se recogieron las caracter&#237;sticas de presentaci&#243;n de la lesi&#243;n&#44; en particular la presencia de los signos y s&#237;ntomas incluidos en las reglas del ABCDE y de los 7 puntos de Glasgow&#44; as&#237; como el retraso en el diagn&#243;stico atribuible al paciente o al m&#233;dico&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En una muestra final de 23 pacientes que pudieron responder finalmente a la encuesta se constat&#243; que el diagn&#243;stico se demor&#243; m&#225;s de un a&#241;o por un retraso en la consulta por parte del paciente en un 30&#44;4&#37;&#46; Por otra parte&#44; hubo una demora de m&#225;s de un a&#241;o atribuible al m&#233;dico que no sospech&#243; el diagn&#243;stico en un 20&#37; de los casos&#46; Respecto a los motivos m&#225;s frecuentes de consulta estos fueron&#58; cambios en el tama&#241;o&#44; en el color&#44; sangrado y herida que no cura&#46; En un 20&#37; de los casos que fueron evaluados por un m&#233;dico la decisi&#243;n de realizar el estudio histol&#243;gico se demor&#243; m&#225;s de un a&#241;o&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Existe un importante retraso en el diagn&#243;stico del MLA debido tanto al paciente como al m&#233;dico&#44; lo que es achacable en parte a una falta de reconocimiento de los signos de alarma en lo que concierne al paciente y al personal sanitario&#46; Las campa&#241;as preventivas del melanoma deber&#237;an poner m&#225;s &#233;nfasis en la posible afectaci&#243;n de las palmas y sobre todo de las plantas&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Background and objective</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Acral lentiginous melanomas &#8212;the melanomas most commonly found on the distal portions of the limbs&#8212; have usually reached more advanced stages than other types of melanoma when diagnosed&#46; Our aim was to describe the clinical presentation of these tumors&#46;</p> <span class="elsevierStyleSectionTitle">Materials and methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Retrospective&#44; descriptive&#44; observational study of cases recorded in the database of the Instituto Valenciano de Oncolog&#237;a&#46; In telephone interviews the patients answered a questionnaire on the presenting features of the lesion&#44; on the presence of signs and symptoms included in the Glasgow 7-point checklist and the ABCDEs of melanoma&#44; and on diagnostic delay attributable to patient or physician&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">In the interviews with the 23 patients who responded to the questionnaire&#44; we detected a diagnostic delay of more than 1 year attributable to the patient &#40;delay in seeking care&#41; in 30&#46;4&#37; of the cases&#46; Diagnostic delay of more than 1 year attributable to the physician &#40;failure to suspect the diagnosis&#41; was identified in 20&#37;&#46; The most frequent reasons for consulting a physician about a lesion were changes in size&#44; changes in color&#44; bleeding&#44; or failure to heal&#46; In 20&#37; of the cases the evaluating physician did not order histology for over a year&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagnostic delay is a significant problem in acral lentiginous melanoma and may be attributable either to patients or to physicians&#8217; failure to recognize warning signs&#46; Melanoma prevention campaigns should place more emphasis on the possibility of melanomas appearing on the palms and&#44; particularly&#44; on the soles&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">D&#58; dorso&#59; Dch&#58; derecho&#59; Iz&#58; izquierdo&#59; Pa&#58; palma&#59; Pl&#58; planta&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Iz&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Dch&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Pa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Iz&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Dch&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Pl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Zona apoyo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Arco plantar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Anterior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Tal&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</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">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tal&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tal&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab182462.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Localizaci&#243;n de la lesi&#243;n</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Tabla 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "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"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Caracter&#237;sticas de la lesi&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Signos y s&#237;ntomas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Porcentaje&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Motivo de consulta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Porcentaje respecto al total de MM &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Porcentaje respecto al total de pacientes sintom&#225;ticos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">N&#250;mero&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">N&#250;mero&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Asimetr&#237;a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \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">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \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="elsevierStyleItalic">Bordes irregulares</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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">&#8805;<span class="elsevierStyleHsp" style=""></span>2 colores</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" 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">&#62;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cambio en</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>Tama&#241;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#44;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;5&#47;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Forma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#44;22 &#40;2&#47;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Color&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#44;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#44;50 &#40;5&#47;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></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="elsevierStyleItalic">Inflamaci&#243;n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">23&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0 &#40;0&#47;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Sangrado</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">58&#44;33 &#40;7&#47;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Prurito</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46; Hematoma4&#46; Verruga&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; Callo5&#46; MM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; No sabe<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46; MM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</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&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab182461.png"
              ]
            ]
          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">Los n&#250;meros en cada personal sanitario se corresponden con el orden con el que el especialista evalu&#243; la lesi&#243;n y el diagn&#243;stico de sospecha realizado&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara">El enfermero &#40;3&#41; sospecha un MM pero lo cura durante 9 meses con nitrato de plata&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara">El cirujano lo remite a enfermer&#237;a para curas&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Personal sanitario consultado&#44; retraso diagn&#243;stico y Breslow de los 23 pacientes encuestados<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliograf&#237;a"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:15 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous melanoma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;F&#46; Thompson"
                            1 => "R&#46;A&#46; Scolyer"
                            2 => "R&#46;F&#46; Kefford"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(05)17951-3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2005"
                        "volumen" => "365"
                        "paginaInicial" => "687"
                        "paginaFinal" => "701"
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Información del artículo
ISSN: 00017310
Idioma original: Español
DOI:10.1016/j.ad.2012.06.006
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