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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diagnosis of melanocytic lesions is a complex process that mainly depends on the microscopic evaluation of biopsy samples&#46; Multiple studies have shown low interobserver diagnostic agreement in such cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1&#44;2</span></a> These studies&#44; however&#44; have largely been small&#44; non-randomized studies or studies that analyzed agreement between experts&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In a recent study&#44; Elmore et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> published the results of the largest study to date to analyze diagnostic concordance in the setting of melanoma and melanocytic proliferations&#46; They studied 187 US pathologists&#44; most of whom &#40;84&#37;&#41; had over 10 years&#8217; experience analyzing melanocytic lesions and 42&#37; of whom were considered an expert in the field&#46; They selected 240 biopsy cases divided into groups of 48&#46; A single hematoxylin-eosin&#8211;stained glass slide was available for each case&#46; A reference diagnosis was established by 3 expert pathologists&#46; Each of the participating pathologists was randomly assigned to a set of 48 cases and asked to diagnose them&#46; The researchers grouped their responses using the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis &#40;MPATH-Dx&#41; tool&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> which consists of 5 diagnostic classes ranging from low risk to high risk &#40;classes <span class="elsevierStyleSmallCaps">i-v</span> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The same slides were re-evaluated at least 8 months later to check intraobserver concordance&#46; The answers were compared with those given by the other pathologists in the group to evaluate interobserver concordance&#46; These answers were then checked against the consensus reference diagnosis to evaluate observer accuracy&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The results for intraobserver concordance varied according to lesion type&#46; Concordance was highest for class <span class="elsevierStyleSmallCaps">i</span> lesions &#40;76&#46;7&#37;&#41; and class <span class="elsevierStyleSmallCaps">v</span> lesions &#40;82&#46;6&#37;&#41;&#44; but was considerably lower &#40;35&#37;-63&#37;&#41; for lesions in the intermediate classes&#46; The results for interobserver concordance were similar &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Observer accuracy also varied significantly by lesion type and was 92&#37; for class <span class="elsevierStyleSmallCaps">i</span> lesions&#44; 25&#37; for class <span class="elsevierStyleSmallCaps">ii</span> lesions&#44; 40&#37; for class <span class="elsevierStyleSmallCaps">iii</span> lesions&#44; 43&#37; for class <span class="elsevierStyleSmallCaps">iv</span> lesions&#44; and 72&#37; for class <span class="elsevierStyleSmallCaps">v</span> lesions&#46; Extrapolation of these results to the level of the population shows a diagnostic error rate of approximately 17&#46;2&#37; &#40;8&#37; for overinterpretation of lesion class and 9&#46;2&#37; for underinterpretation&#41;&#46; They also show that based on the reference diagnosis&#44; 16&#37; of class <span class="elsevierStyleSmallCaps">iv</span> or <span class="elsevierStyleSmallCaps">v</span> lesions &#40;invasive melanomas&#41; would be classified as class <span class="elsevierStyleSmallCaps">i</span> or <span class="elsevierStyleSmallCaps">ii</span> lesions&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In brief&#44; the study by Elmore et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> shows a low level of diagnostic concordance and accuracy for intermediate-class lesions such as dysplastic nevi&#44; melanomas in situ&#44; and invasive T1a melanomas that could result in over 17&#37; of patients receiving incorrect treatments&#46; Our study has several limitations&#44; including the evaluation of a single glass slide&#44; the nonuse of immunohistochemical staining and molecular assays&#44; and the impossibility of asking for a second opinion&#46; Without these limitations&#44; the concordance and accuracy results may have been better&#46; The results of our study&#44; the largest of its type to date&#44; indicate the need to improve current training systems and enhance the skills of specialists in the diagnosis and staging of melanocytic lesions&#46; They also show the importance of using complementary diagnostic tools&#46; Finally&#44; the importance of adequate clinicopathologic correlation should not be overlooked&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples&#58; Common melanocytic nevus&#44; blue nevus&#44; halo nevus&#44; nevus with mild dysplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class II Low-level risk for local proliferation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples&#58; Typical Spitz nevus&#44; nevus with moderate dysplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class III Higher likelihood of local tumor progression</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples&#58; Spitz tumor&#44; nevus with severe dysplasia&#44; melanoma in situ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class IV High risk of locoregional progression</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples&#58; Invasive T1a melanoma&#44; lentigo maligna melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">V High risk of regional or distant metastasis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples&#58; Invasive melanoma<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>T1b&#44; nodular melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Foro de Residentes
Histologic Diagnosis of Melanocytic Lesions and Melanoma: Real Challenges
Diagnóstico histológico de lesiones melanocíticas y melanoma: todo un desafío
D. Morgado-Carrasco
Autor para correspondencia
morgadodaniel8@gmail.com

Corresponding author.
, S.S. Ertekin, A. Combalia, L. Ferrandiz
Unidad de Melanoma, Servicio de Dermatología, Hospital Clínic de Barcelona, Barcelona, España
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    "titulo" => "Histologic Diagnosis of Melanocytic Lesions and Melanoma&#58; Real Challenges"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diagnosis of melanocytic lesions is a complex process that mainly depends on the microscopic evaluation of biopsy samples&#46; Multiple studies have shown low interobserver diagnostic agreement in such cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1&#44;2</span></a> These studies&#44; however&#44; have largely been small&#44; non-randomized studies or studies that analyzed agreement between experts&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In a recent study&#44; Elmore et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> published the results of the largest study to date to analyze diagnostic concordance in the setting of melanoma and melanocytic proliferations&#46; They studied 187 US pathologists&#44; most of whom &#40;84&#37;&#41; had over 10 years&#8217; experience analyzing melanocytic lesions and 42&#37; of whom were considered an expert in the field&#46; They selected 240 biopsy cases divided into groups of 48&#46; A single hematoxylin-eosin&#8211;stained glass slide was available for each case&#46; A reference diagnosis was established by 3 expert pathologists&#46; Each of the participating pathologists was randomly assigned to a set of 48 cases and asked to diagnose them&#46; The researchers grouped their responses using the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis &#40;MPATH-Dx&#41; tool&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> which consists of 5 diagnostic classes ranging from low risk to high risk &#40;classes <span class="elsevierStyleSmallCaps">i-v</span> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The same slides were re-evaluated at least 8 months later to check intraobserver concordance&#46; The answers were compared with those given by the other pathologists in the group to evaluate interobserver concordance&#46; These answers were then checked against the consensus reference diagnosis to evaluate observer accuracy&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The results for intraobserver concordance varied according to lesion type&#46; Concordance was highest for class <span class="elsevierStyleSmallCaps">i</span> lesions &#40;76&#46;7&#37;&#41; and class <span class="elsevierStyleSmallCaps">v</span> lesions &#40;82&#46;6&#37;&#41;&#44; but was considerably lower &#40;35&#37;-63&#37;&#41; for lesions in the intermediate classes&#46; The results for interobserver concordance were similar &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Observer accuracy also varied significantly by lesion type and was 92&#37; for class <span class="elsevierStyleSmallCaps">i</span> lesions&#44; 25&#37; for class <span class="elsevierStyleSmallCaps">ii</span> lesions&#44; 40&#37; for class <span class="elsevierStyleSmallCaps">iii</span> lesions&#44; 43&#37; for class <span class="elsevierStyleSmallCaps">iv</span> lesions&#44; and 72&#37; for class <span class="elsevierStyleSmallCaps">v</span> lesions&#46; Extrapolation of these results to the level of the population shows a diagnostic error rate of approximately 17&#46;2&#37; &#40;8&#37; for overinterpretation of lesion class and 9&#46;2&#37; for underinterpretation&#41;&#46; They also show that based on the reference diagnosis&#44; 16&#37; of class <span class="elsevierStyleSmallCaps">iv</span> or <span class="elsevierStyleSmallCaps">v</span> lesions &#40;invasive melanomas&#41; would be classified as class <span class="elsevierStyleSmallCaps">i</span> or <span class="elsevierStyleSmallCaps">ii</span> lesions&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In brief&#44; the study by Elmore et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> shows a low level of diagnostic concordance and accuracy for intermediate-class lesions such as dysplastic nevi&#44; melanomas in situ&#44; and invasive T1a melanomas that could result in over 17&#37; of patients receiving incorrect treatments&#46; Our study has several limitations&#44; including the evaluation of a single glass slide&#44; the nonuse of immunohistochemical staining and molecular assays&#44; and the impossibility of asking for a second opinion&#46; Without these limitations&#44; the concordance and accuracy results may have been better&#46; The results of our study&#44; the largest of its type to date&#44; indicate the need to improve current training systems and enhance the skills of specialists in the diagnosis and staging of melanocytic lesions&#46; They also show the importance of using complementary diagnostic tools&#46; Finally&#44; the importance of adequate clinicopathologic correlation should not be overlooked&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Morgado-Carrasco D&#44; Ertekin SS&#44; Combalia A&#44; Ferrandiz L&#46; Diagn&#243;stico histol&#243;gico de lesiones melanoc&#237;ticas y melanoma&#58; todo un desaf&#237;o&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;825&#8211;826&#46;</p>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; MPATH-Dx&#44; Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sources&#58; Elmore et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> Piepkorn et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MPATH-Dx Class&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intraobserver Concordance &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interobserver Concordance &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic Accuracy &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class I No apparent risk for local proliferation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples&#58; Common melanocytic nevus&#44; blue nevus&#44; halo nevus&#44; nevus with mild dysplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class II Low-level risk for local proliferation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples&#58; Typical Spitz nevus&#44; nevus with moderate dysplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class III Higher likelihood of local tumor progression</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples&#58; Spitz tumor&#44; nevus with severe dysplasia&#44; melanoma in situ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class IV High risk of locoregional progression</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples&#58; Invasive T1a melanoma&#44; lentigo maligna melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">V High risk of regional or distant metastasis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                          "autores" => array:6 [
                            0 => "S&#46; Patrawala"
                            1 => "A&#46; Maley"
                            2 => "C&#46; Greskovich"
                            3 => "L&#46; Stuart"
                            4 => "D&#46; Parker"
                            5 => "R&#46; Swerlick"
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                      "doi" => "10.1016/j.jaad.2015.09.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2016"
                        "volumen" => "74"
                        "paginaInicial" => "75"
                        "paginaFinal" => "80"
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                      "titulo" => "Discordance in the histopathologic diagnosis of melanoma at a melanoma referral center"
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                          "etal" => false
                          "autores" => array:3 [
                            0 => "B&#46;A&#46; Shoo"
                            1 => "R&#46;W&#46; Sagebiel"
                            2 => "M&#46; Kashani-Sabet"
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                      "doi" => "10.1016/j.jaad.2009.09.043"
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                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2010"
                        "volumen" => "62"
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                      "titulo" => "Pathologists&#8217; diagnosis of invasive melanoma and melanocytic proliferations&#58; Observer accuracy and reproducibility study"
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