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la funci&#243;n hep&#225;tica&#44; el futuro remanente&#44; las comorbilidades y el estado funcional del paciente<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">El trasplante hep&#225;tico se ha considerado el tratamiento de elecci&#243;n con intenci&#243;n curativa para pacientes seleccionados&#44; con unas tasas de supervivencia a los cinco a&#241;os sobre el 70&#37;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#8211;6</span></a>&#46; No obstante&#44; a pesar de los criterios de selecci&#243;n de los pacientes candidatos a trasplante para el tratamiento del CHC&#44; las tasas de recurrencia del CHC oscilan entre el 8 y el 20&#37;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En 1996&#44; Mazzaferro et al&#46; publicaron la primera serie exitosa de pacientes cirr&#243;ticos sometidos a trasplante hep&#225;tico por CHC irresecable&#44; estableciendo unos criterios de selecci&#243;n mundialmente aceptados&#44; conocidos como criterios de Mil&#225;n &#40;MC&#41;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a>&#44; considerados el est&#225;ndar de referencia para la selecci&#243;n de pacientes con CHC candidatos a trasplante<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a>&#44; con unas tasas de supervivencia global y libre de enfermedad a los cuatro a&#241;os cercanas al 75&#37; y al 92&#37;&#44; respectivamente<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a>&#46; A pesar del &#233;xito&#44; han sido discutidos en los &#250;ltimos a&#241;os&#44; debido a su car&#225;cter restrictivo para la indicaci&#243;n de trasplante&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Por ello&#44; diferentes grupos han valorado ampliar estos criterios&#44; desarrollando nuevos modelos m&#225;s flexibles que permitan a un mayor n&#250;mero de pacientes optar al trasplante como tratamiento&#46; 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evitar la progresi&#243;n tumoral de pacientes en lista de espera para el trasplante hep&#225;tico<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#44;14</span></a> y reducir la carga tumoral de pacientes que no cumplen criterios de trasplante &#40;<span class="elsevierStyleItalic">downstaging</span>&#41;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#44;15</span></a>&#46; Las terapias locorregionales m&#225;s utilizadas como terapia puente son la radiofrecuencia &#40;RF&#41; y la quimioembolizaci&#243;n transarterial &#40;TACE&#41;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">15&#8211;18</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El objetivo de este trabajo fue realizar un an&#225;lisis global de las caracter&#237;sticas demogr&#225;ficas&#44; cl&#237;nicas y biol&#243;gicas de los pacientes trasplantados por CHC&#44; evaluar su supervivencia y recurrencia tumoral y comparar estas variables entre los pacientes que cumpl&#237;an los MC frente a los que los exced&#237;an&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materiales y m&#233;todos</span><p id="par0040" class="elsevierStylePara elsevierViewall">Estudio observacional&#44; 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pero con previsi&#243;n de tiempo prolongado en lista de espera fueron sometidos a terapias puente&#46; Los tratamientos empleados fueron la TACE y la RF&#44; indicando esta &#250;ltima como tratamiento para n&#243;dulos menores de 15<span class="elsevierStyleHsp" style=""></span>mm y &#250;nicos&#44; repitiendo las sesiones en aquellos pacientes con sospecha de tumor viable en las pruebas de control&#44; ya sea mediante ecograf&#237;a&#44; resonancia magn&#233;tica o TAC&#46; Se usaron los criterios <span class="elsevierStyleItalic">Liver Imaging Reporting and Data System</span> &#40;LI-RADS&#41; en pacientes con CHC tratado &#40;LR-TR&#41; para valorar la respuesta radiol&#243;gica&#44; estableci&#233;ndose tres categor&#237;as&#58; LR-TR no viable LR-TR viable y LR-TR equ&#237;voco&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">El periodo de seguimiento m&#237;nimo postrasplante se estableci&#243; en 18 meses&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Para el an&#225;lisis por grupos&#44; se defini&#243; el grupo de MC como aquellos pacientes que en las pruebas de imagen pretrasplante presentaban un CHC &#250;nico menor de 5<span class="elsevierStyleHsp" style=""></span>cm o 2 o 3 lesiones menores de 3<span class="elsevierStyleHsp" style=""></span>cm&#46; El grupo No Criterios de Mil&#225;n &#40;NMC&#41; fueron pacientes con CHC que exced&#237;a los MC pero que no superaban los criterios <span class="elsevierStyleItalic">Up to Seven</span>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Las variables analizadas incluyeron&#58; datos demogr&#225;ficos&#44; cl&#237;nicos&#44; bioqu&#237;micos&#44; patol&#243;gicas y evoluci&#243;n seguida&#46; Se recogi&#243; la carga tumoral total &#40;TBS&#41; de los pacientes&#44; calculado mediante la ecuaci&#243;n propuesta por Sasaki et al&#46; y dividiendo por categor&#237;as de riesgo<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">An&#225;lisis estad&#237;stico</span><p id="par0070" class="elsevierStylePara elsevierViewall">Realizamos un an&#225;lisis estad&#237;stico descriptivo donde las variables cuantitativas se expresaron como media y desviaciones est&#225;ndar o mediana y rango intercuart&#237;lico&#44; seg&#250;n la distribuci&#243;n&#46; Se realiz&#243; la prueba de Shapiro-Wilk para valorar la normalidad de las variables continuas&#46; Las variables categ&#243;ricas se expresaron mediante tablas de frecuencias y porcentajes&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Para contrastar los resultados entre el grupo de pacientes MC&#47;NMC con respecto a las variables cuantitativas&#44; se us&#243; la prueba <span class="elsevierStyleItalic">t</span> de Student o <span class="elsevierStyleItalic">U</span> de Mann-Whitney&#44; seg&#250;n correspondiera&#46; Las variables categ&#243;ricas se compararon con la prueba de <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> o el test exacto de Fisher&#46; Por otro lado&#44; se estim&#243; la funci&#243;n de supervivencia global y libre de enfermedad mediante el m&#233;todo de Kaplan-Meier tanto de manera global como estratificado por los criterios de inclusi&#243;n MC&#47;NMC&#46; Por &#250;ltimo&#44; se aplic&#243; la prueba de <span class="elsevierStyleItalic">log rank</span> para comparar entre grupo MC&#47;NMC&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Los c&#225;lculos se realizaron con el programa estad&#237;stico STATA vs14&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Consideraciones &#233;ticas</span><p id="par0085" class="elsevierStylePara elsevierViewall">En el siguiente estudio se han seguido los protocolos del centro sobre la publicaci&#243;n de datos de los pacientes que intervienen en el mismo&#44; preserv&#225;ndose en el anonimato los datos de los mismos&#46; El consentimiento informado no se solicit&#243; para la publicaci&#243;n&#44; porque en el presente art&#237;culo no se publican datos personales que permita identificar al paciente&#46; El trabajo cumple con la normativa vigente en investigaci&#243;n bio&#233;tica y fue aprobado por el comit&#233; &#233;tico del hospital correspondiente&#44; Hospital Universitario Virgen de las Nieves&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="par0090" class="elsevierStylePara elsevierViewall">Del total de trasplantes realizados &#40;397&#41;&#44; 104 casos fueron por CHC&#46; De ellos&#44; ocho pacientes fueron excluidos del estudio&#58; uno por historia duplicada&#44; otro por corresponder a un colangiocarcinoma en el explante&#44; un tercero por exitus intraoperatorio por fallo hemodin&#225;mico y cinco por fallecimiento en el posoperatorio inmediato &#40;dos casos de no funci&#243;n primaria del injerto&#44; dos por trombosis aguda de la arteria hep&#225;tica&#44; y uno por sepsis abdominal&#41;&#46; Finalmente 96 pacientes fueron analizados&#44; 78 de ellos &#40;81&#46;2&#37;&#41; cumpl&#237;an MC para trasplante hep&#225;tico&#44; frente a los 18 pacientes &#40;18&#46;8&#37;&#41; que exced&#237;an estos criterios &#40;NMC&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se describen las caracter&#237;sticas y variables demogr&#225;ficas analizadas&#44; tanto a nivel global&#44; como por grupos&#46; El sexo predominante fue el masculino &#40;81&#37;&#41;&#44; con una edad media de 58&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6 a&#241;os&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">El an&#225;lisis de las variables cl&#237;nicas y bioqu&#237;micas se resume en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46; Las terapias puente se ofrecieron al 100&#37; de los pacientes que exced&#237;an los MC&#44; con sesiones que fueron repetidas hasta conseguir la infraestadificaci&#243;n frente al 92&#46;4&#37; de los que cumpl&#237;an los criterios de inicio&#46; El tratamiento m&#225;s frecuente fue la TACE&#44; realizado en el 87&#46;5&#37;&#46; El n&#250;mero de sesiones medio fue de 1&#46;6 en la muestra global&#44; aunque el grupo NMC precis&#243; de mayor n&#250;mero de sesiones que aquellos que cumpl&#237;an los MC &#40;2&#46;1 vs&#46; 1&#46;5&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0045&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">De los 78 pacientes que recibieron tratamiento locorregional como puente al trasplante&#44; se realiz&#243; pruebas de imagen de reevaluaci&#243;n a 71 pacientes &#40;90&#46;5&#37;&#41;&#58; 8 &#40;8&#46;2&#37;&#41; mediante ecograf&#237;a&#44; 68 &#40;70&#46;1&#37;&#41; resonancia magn&#233;tica&#44; y 12 &#40;12&#46;4&#37;&#41; TAC&#46; De estos 71 pacientes reevaluados&#44; el 59&#37; se catalogaron como LR-TR no viable&#44; el 32&#46;5&#37; como LR-TR viable y el resto &#40;8&#46;5&#37;&#41; LR-TR equ&#237;voco&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">En cuanto al an&#225;lisis de las variables cl&#237;nico-patol&#243;gicas &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#44; sobre los 78 pacientes tratados mediante TACE o RF previo al trasplante hep&#225;tico&#44; se constat&#243; en un 87&#46;73&#37; la presencia de necrosis tumoral en el an&#225;lisis histopatol&#243;gico del explante hep&#225;tico&#46; Esta fue completa en un 54&#46;44&#37; de casos y parcial en un 33&#46;33&#37; de los n&#243;dulos tratados&#44; sin haber diferencias significativas entre los grupos analizados &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;153&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Respecto a la correlaci&#243;n del grado de necrosis tumoral y la categor&#237;a LR-TR postratamiento&#44; el 37&#46;1&#37; de los pacientes que se evaluaron como LR-TR viable hab&#237;an presentado &#171;respuesta total&#187; vs&#46; 62&#46;9&#37; &#171;no respuesta total&#187;&#46; En cuanto a los evaluados como LR-TR no viable&#44; el 59&#46;2&#37; hab&#237;an presentado una &#171;respuesta total&#187; vs&#46; el 40&#46;8&#37; una &#171;no respuesta total&#187;&#46; Y finalmente&#44; el 62&#46;5&#37; de los pacientes evaluados como LR-TR equ&#237;voco ten&#237;an una &#171;respuesta completa&#187; en comparaci&#243;n con el 37&#46;5&#37; con &#171;no respuesta completa&#187;&#44; siendo estas diferencias no significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;123&#41;&#46; No se observaron diferencias estad&#237;sticamente significativas en la supervivencia global y libre de enfermedad entre los grupos de LR-TR viable&#44; no viable y equ&#237;voco &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;3484 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4152&#44; respectivamente&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">El tiempo medio en lista de espera para trasplante fue de 183<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>129 d&#237;as&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">En cuanto a las variables bioqu&#237;micas analizadas&#44; se constat&#243; que los pacientes clasificados como grados 1 y 2 de alb&#250;mina-bilirrubina &#40;ALBI&#41; fueron los m&#225;s frecuentes&#44; siendo el 47&#37; de los pacientes NMC clasificados como grado 1 frente al 20&#46;78&#37; de los pacientes MC &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;042&#41;&#46; La media global de alfafetoprote&#237;na &#40;AFP&#41; preoperatoria fue de 9&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15 ng&#47;mL&#44; siendo en el grupo MC 8&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26 ng&#47;mL frente a 10&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6 ng&#47;mL en el grupo de pacientes NMC&#44; siendo estas diferencias no significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;730&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Por otro lado&#44; se demostr&#243; que los pacientes que inicialmente estaban fuera de los MC presentaban mayor n&#250;mero de n&#243;dulos &#40;1&#46;6 vs&#46; 3&#46;5 n&#243;dulos p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#44; mayor tama&#241;o de las lesiones principales &#40;24&#46;38 vs&#46; 38&#46;55<span class="elsevierStyleHsp" style=""></span>mm&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41; y mayor tasa de CHC bilobular &#40;21&#46;79 vs&#46; 72&#46;22&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#44; as&#237; como mayor carga tumoral tanto en valores absolutos &#40;3&#46;02<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;8 vs&#46; 6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;2&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;00&#41; como por estratificaci&#243;n por grupos de riesgo&#59; as&#237;&#44; el 77&#46;8&#37; de los pacientes NMC se catalogar&#237;a como grupo de alto TBS frente al 17&#46;1&#37; de los pacientes MC &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">En cuanto a las complicaciones posoperatorias&#44; se registr&#243; mayor porcentaje de complicaciones de la v&#237;a biliar &#40;en forma de colangiopat&#237;a isqu&#233;mica&#41; en pacientes del grupo MC frente a los del grupo NMC &#40;18&#46;9&#37; vs&#46; 0&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">Durante el periodo de seguimiento&#44; fallecieron 31 pacientes &#40;32&#46;3&#37;&#41;&#44; 22 del grupo MC y nueve del grupo NMC&#46; El 52&#46;1&#37; fueron exitus en los 12 primeros meses postrasplante&#44; en ning&#250;n caso por recidiva por CHC&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Las tasas de supervivencia global a los tres&#44; seis&#44; 12&#44; 24 y 48 meses fue del 98&#37;&#44; 96&#37;&#44; 87&#37;&#44; 77&#37; y 69&#37;&#44; respectivamente&#46; Cuando analizamos la supervivencia global por grupos&#44; se apreci&#243; una mayor supervivencia a los 12&#44; 24 y 48 meses en el grupo de pacientes MC frente a los pacientes NMC &#40;89&#46;7&#37;&#44; 804&#37; y 71&#44;9&#37; vs&#46; 77&#44;7&#46;&#37;&#44; 65&#46;6&#37; y 57&#46;4&#37;&#44; respectivamente&#41;&#44; siendo estas diferencias no significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;09&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Siete &#40;7&#46;3&#37;&#41; pacientes presentaron recidiva del CHC&#44; tres de ellos dentro del grupo MC y cuatro del grupo NMC&#44; presentando una supervivencia libre de enfermedad a los 12&#44; 24 y 48 meses de 100&#37;&#44; 96&#46;9&#37; y 96&#46;9&#37; en el grupo MC vs&#46; 93&#46;3&#37;&#44; 72&#37; y 72&#37; en el grupo NMC&#44; siendo estas diferencias estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0027&#41;&#46; El 80&#37; de las recidivas ocurrieron en los primeros 18 meses postrasplante &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 2</a>&#41;&#46; Todos los pacientes que recidivaron presentaron una enfermedad extrahep&#225;tica&#44; siendo la localizaci&#243;n m&#225;s frecuente las met&#225;stasis &#243;seas y peritoneales&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discusi&#243;n</span><p id="par0155" class="elsevierStylePara elsevierViewall">En nuestro an&#225;lisis&#44; obtuvimos una tasa de recurrencia global del 7&#46;3&#37;&#44; dato ligeramente inferior a las tasas de otros trabajos publicados&#44; que oscilan entre el 8-20&#37;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;8&#44;13&#44;15&#44;19</span></a> Los resultados de este estudio revelan que existen diferencias en cuanto a la supervivencia libre de enfermedad postrasplante hep&#225;tico entre los pacientes trasplantados hep&#225;ticos dentro de los MC frente a los que los exced&#237;an&#44; sin existir diferencia significativa en cuanto a la supervivencia global entre ambos grupos&#46; Kardashian et al&#46; realizaron una revisi&#243;n del Registro norteamericano&#44; con una amplia casu&#237;stica &#40;3&#44;570 pacientes con tumores dentro de los MC&#44; 789 exced&#237;an los MC&#44; de los cuales 465 pudieron ser sometidos a <span class="elsevierStyleItalic">downstaging</span>&#41;&#46; Determinaron que la supervivencia postrasplante global y libre de enfermedad resultaron significativamente inferiores en estos tumores fuera de criterios&#58; con MC el porcentaje de recurrencia fue del 11&#37;&#59; este porcentaje ascendi&#243; en el grupo sometido al <span class="elsevierStyleItalic">downstaging</span> al 16&#37;&#44; y en pacientes en los que no se pudo hacer el <span class="elsevierStyleItalic">downstaging</span> lleg&#243; al 32&#37;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a>&#46; Esos datos se corresponden con los obtenidos en nuestra serie&#44; con menores tasas de recurrencia en nuestro caso&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">En nuestro centro&#44; se han empleado los tratamientos locorregionales en los pacientes con CHC dentro de Mil&#225;n como tratamiento puente hasta el trasplante en la mayor&#237;a de los casos&#44; ya que el tiempo medio en lista de espera supera los seis meses&#46; Esto concuerda con la recomendaci&#243;n emitida en 2015 por la <span class="elsevierStyleItalic">United Network for Organ Sharing</span>&#44; la <span class="elsevierStyleItalic">European Association for the Study of the Liver</span> y la <span class="elsevierStyleItalic">European Organisation for Research and Treatment of Cancer</span>&#44; sugiriendo el uso de estas terapias locorregionales ante listas mayores a seis meses&#44; por el riesgo de progresi&#243;n y <span class="elsevierStyleItalic">dropout</span><a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">21&#44;22</span></a>&#46; El objetivo principal de estas terapias es ralentizar la progresi&#243;n tumoral hasta que se disponga de un &#243;rgano adecuado para el paciente&#46; De esta forma se minimizar&#237;a la posibilidad de exclusi&#243;n para trasplante por progresi&#243;n del CHC&#44; con tasas que pueden llegar hasta el 10-20&#37;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19&#8211;21</span></a>&#46; Adem&#225;s&#44; parecen existir beneficios de estos tratamientos a nivel oncol&#243;gico&#46; En varios de los estudios publicados&#44; los pacientes que presentaron mayor respuesta tumoral tras el tratamiento locorregional tuvieron mejores resultados despu&#233;s del trasplante<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">22&#8211;24</span></a>&#46; En unidades de trasplante con tiempos de lista de espera m&#225;s cortos&#44; el papel de las terapias locorregionales en pacientes dentro de MC no est&#225; claramente definido<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a>&#46; A pesar del voluminoso n&#250;mero de trabajos y estudios publicados sobre la expansi&#243;n de criterios para indicar trasplante hep&#225;tico en el CHC y el uso cada vez m&#225;s extendido de las terapias para infraestadiar los pacientes&#44; no se ha establecido a&#250;n ning&#250;n protocolo de manejo&#44; y hay poca definici&#243;n en cuanto a los resultados tras el <span class="elsevierStyleItalic">downstaging</span>&#46; Adem&#225;s&#44; las tasas de &#233;xito de los tratamientos locorregionales utilizados para el <span class="elsevierStyleItalic">downstaging</span> son extremadamente variables &#40;24-90&#37;&#41;&#44; debido principalmente&#44; a los dise&#241;os retrospectivos de los estudios publicados&#59; y por no haber una definici&#243;n clara en cuanto a la modalidad de tratamiento&#44; volumen tumoral a tratar y definici&#243;n de respuesta al tratamiento&#46; En 2015 se public&#243; una revisi&#243;n sistem&#225;tica que concluy&#243; que exist&#237;a una importante heterogeneidad en los trabajos en cuanto a la definici&#243;n de la carga tumoral&#44; tiempo en lista de espera&#44; los protocolos utilizados para infraestadiar&#44; y la evaluaci&#243;n de respuesta al tratamiento<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Cada vez existen menos dudas de que los criterios morfol&#243;gicos centrados &#250;nicamente en el tama&#241;o y el n&#250;mero del tumor son insuficientes en la selecci&#243;n de pacientes para el trasplante hep&#225;tico&#44; por lo que deben combinarse con marcadores biol&#243;gicos&#44; inflamatorios&#44; radiol&#243;gicos&#44; patol&#243;gicos y gen&#233;ticos que predigan el comportamiento biol&#243;gico del tumor&#46; Son varios los estudios publicados que han demostrado que los niveles de AFP por encima de 400 ng&#47;mL preoperatorios&#44; los grados de diferenciaci&#243;n del tumor desfavorables &#40;3 y 4&#41;&#44; la positividad en la tomograf&#237;a por emisi&#243;n de positrones&#44; los tumores multilobulares o la presencia de invasi&#243;n vascular tanto micro como macrosc&#243;pica predicen la posibilidad de recidiva de forma m&#225;s precisa que los MC de forma aislada<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">26&#8211;29</span></a>&#46; Liang et al&#46; analizaron los pacientes trasplantados por CHC con criterios expandidos que presentaron recurrencia de la enfermedad&#46; Se evidenci&#243; que aquellos que recidivaban ten&#237;an un mayor tama&#241;o tumoral total y del n&#243;dulo tumoral principal que aquellos que no recidivaron&#44; lo que les permiti&#243; establecer unas nuevas indicaciones m&#225;s amplias&#46; De esta forma&#44; con tumores con un tama&#241;o m&#225;ximo de hasta 6<span class="elsevierStyleHsp" style=""></span>cm y una sumatoria tumoral total de hasta 10 cm&#44; obten&#237;an unas tasas de supervivencia tanto global y libre de enfermedad a los cinco a&#241;os del 77&#46;7&#37; y 20&#46;5&#37;&#44; respectivamente&#44; datos comparables a los obtenidos cumpliendo MC&#46; As&#237; se beneficiar&#237;an hasta en un 35&#37; m&#225;s los posibles candidatos a trasplante<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a>&#46; Estos resultados van en el mismo sentido que nuestro caso&#44; aunque dada la escasa muestra y el escaso n&#250;mero de recidivas&#44; no hemos podido establecer qu&#233; variables se asocian a la recidiva&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Este estudio presenta una serie de limitaciones&#46; En primer lugar&#44; es una serie retrospectiva con un dise&#241;o no aleatorizado&#46; Por otra parte&#44; el tama&#241;o de la serie es reducido para poder realizar un an&#225;lisis multivariante que identifique par&#225;metros predictores de recurrencia de la enfermedad de forma independiente y as&#237; obtener conclusiones s&#243;lidas&#46; En tercer lugar&#44; no se han valorado marcadores g&#233;nicos o moleculares que pueden condicionar la mayor o menor agresividad tumoral y su tendencia a la recidiva&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Como conclusi&#243;n&#44; seg&#250;n nuestro estudio&#44; la infraestadificaci&#243;n o <span class="elsevierStyleItalic">downstaging</span> de los pacientes candidatos a trasplante que presentan CHC m&#225;s all&#225; de los MC es una opci&#243;n segura permiti&#233;ndoles optar al trasplante&#44; con tasas de supervivencia libre de enfermedad menores que los pacientes trasplantados que cumplen estos criterios&#44; aunque sin diferencias significativas en cuanto a la supervivencia global&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Son necesarios estudios prospectivos con mayor tama&#241;o muestral que confirmen estos resultados&#44; analizar las variables asociadas a la recidiva y estandarizar las estrategias de infraestadiaje&#44; el tipo de tratamiento locorregional&#44; la evaluaci&#243;n m&#225;s adecuada de la respuesta&#44; as&#237; como el seguimiento posterior para mejorar los resultados&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Financiaci&#243;n</span><p id="par0185" class="elsevierStylePara elsevierViewall">No se recibi&#243; ning&#250;n tipo de financiaci&#243;n para la elaboraci&#243;n de este trabajo&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicto de intereses</span><p id="par0190" class="elsevierStylePara elsevierViewall">No existe conflicto de intereses con relaci&#243;n al art&#237;culo que se remite para publicaci&#243;n&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010"><span class="elsevierStyleItalic">Introducci&#243;n y objetivos</span></span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Los criterios de Mil&#225;n &#40;MC&#41; han sido discutidos debido a su car&#225;cter restrictivo&#46; Se ha propuesto su ampliaci&#243;n y el empleo de terapias locorregionales que infraestadifiquen y aumenten los candidatos a trasplante&#46; Nuestro estudio analiza los resultados de los pacientes trasplantados por carcinoma hepatocelular &#40;CHC&#41; que cumpl&#237;an MC y aquellos que los exced&#237;an&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015"><span class="elsevierStyleItalic">Materiales y m&#233;todos</span></span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; retrospectivo y unic&#233;ntrico sobre trasplantados hep&#225;ticos por CHC entre el 2010-2021&#46; Se analizaron variables demogr&#225;ficas&#44; cl&#237;nicas y supervivencia global y libre de enfermedad&#46; Se aplic&#243; la prueba <span class="elsevierStyleItalic">t</span> de Student o la de <span class="elsevierStyleItalic">U</span> de Mann-Whitney para variables cuantitativas&#59; para categ&#243;ricas el test exacto de Fisher&#46; Se estim&#243; la funci&#243;n de supervivencia mediante el m&#233;todo de Kaplan-Meier y se aplic&#243; el <span class="elsevierStyleItalic">log rank</span> para comparar entre grupos&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020"><span class="elsevierStyleItalic">Resultados</span></span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">De los pacientes 96 trasplantados&#44; 78 cumpl&#237;an MC y 18 los exced&#237;an&#46; Los pacientes que no cumpl&#237;an los MC presentaban mayor n&#250;mero de n&#243;dulos &#40;1&#44;6 vs&#46; 3&#44;5 n&#243;dulos &#91;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#46;000&#93;&#41;&#44; mayor tama&#241;o de las lesiones principales &#40;24&#44;38 vs&#46; 38&#44;55<span class="elsevierStyleHsp" style=""></span>mm&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41; y mayor tasa de CHC bilobular &#40;21&#46;79&#37; vs&#46; 72&#46;22&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#44; as&#237; como mayor carga tumoral&#46; No hubo diferencias significativas en cuanto a la supervivencia global&#44; aunque s&#237; en cuanto a la supervivencia libre de enfermedad&#44; siendo menor en el grupo que exced&#237;a los criterios&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025"><span class="elsevierStyleItalic">Conclusi&#243;n</span></span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Los pacientes infraestadiados con terapias locorregionales presentan tasas de supervivencia libre de enfermedad menores a los pacientes que cumplen los MC&#44; sin diferencias significativas en cuanto a la supervivencia global&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035"><span class="elsevierStyleItalic">Introduction and aim</span></span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The Milan criteria have been the subject of discussion in recent years due to their restrictive nature&#46; Expansion of the criteria and the use of locoregional therapies to downstage patients and increase the number of transplant candidates have been proposed&#46; Our study analyzed the results of patients that underwent transplant due to hepatocellular carcinoma&#44; comparing those that met the Milan criteria and those that exceeded them&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040"><span class="elsevierStyleItalic">Materials and methods</span></span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A retrospective&#44; observational&#44; single-center study was conducted on liver transplantations due to hepatocellular carcinoma&#44; within the time frame of 2010-2021&#46; Demographic and clinical variables&#44; overall survival&#44; and disease-free survival were analyzed&#46; The Student&#39;s t test or Mann-Whitney U test were applied for the quantitative variables and the Fisher&#39;s exact test for the categorical variables&#46; The survival function was estimated through the Kaplan-Meier method and the log-rank test was applied for comparing the groups&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045"><span class="elsevierStyleItalic">Results</span></span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Of the 96 transplanted patients&#44; 78 met the Milan criteria and 18 exceeded them&#46; Patients that did not meet the Milan criteria had a higher number of nodules &#40;1&#46;6 vs 3&#46;5 nodules&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#44; larger main lesions &#40;24&#46;38 vs 38&#46;55<span class="elsevierStyleHsp" style=""></span>mm&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#44; a higher bilobar hepatocellular carcinoma rate &#40;21&#46;79&#37; vs 72&#46;22&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#44; and higher tumor burden&#46; There were no significant differences regarding overall survival&#44; but there was a lower rate of disease-free survival in the group exceeding the criteria&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050"><span class="elsevierStyleItalic">Conclusi&#243;n</span></span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Downstaged patients that received locoregional therapies had lower disease-free survival rates than patients that met the Milan criteria&#44; but there were no significant differences regarding overall survival&#46;</p></span>"
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tiempo lista de espera &#40;d&#237;as&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">175&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>138&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">186&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>60&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento preoperatorio &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia hospitalaria &#40;d&#237;as&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tiempo seguimiento &#40;meses&#41;&#44; mediana &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">52&#40;49&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">53 &#40;44&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">54 &#40;24&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;709<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#165;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Grupo sangu&#237;neo</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&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">35&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50&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">46&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;417<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">¿</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>B&nbsp;\t\t\t\t\t\t\n
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                  \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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&#46;6&nbsp;\t\t\t\t\t\t\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-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MELD&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\ttop\n
                  \t\t\t\t">12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">AFP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Clasificaci&#243;n ALBI &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">72&#46;7&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">6&#46;7&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
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                  \t\t\t\t">6&#46;5&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
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                  \t\t\t\t">11&#46;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="" 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></tbody></table>
                  """
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            1 => array:3 [
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        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" 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" scope="col" style="border-bottom: 2px solid black">Serie global&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grupo MC&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" scope="col" style="border-bottom: 2px solid black">Grupo NMC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Respuesta al tratamiento locorregional &#40;&#37;&#41;</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="" 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
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                  \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
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&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">12&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15&#46;1&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">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&#46;153<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">¿</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Repuesta parcial&nbsp;\t\t\t\t\t\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">33&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;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">47&#46;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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Respuesta completa&nbsp;\t\t\t\t\t\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">54&#46;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">54&#46;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">52&#46;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="" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">N&#250;mero de n&#243;dulos</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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;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">1&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;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">3&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;000<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">&#165;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tama&#241;o n&#243;dulo mayor &#40;mm&#41;</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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;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">24&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;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&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>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">0&#46;000<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">&#167;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">TBS score</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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;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">3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;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">6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;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">0&#46;000<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">&#165;</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 ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">TBS grupos &#40;&#37;&#41;</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="" valign="\n
                  \t\t\t\t\ttop\n
                  \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="" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alto&nbsp;\t\t\t\t\t\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">29&#46;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">17&#46;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">77&#46;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">0&#46;000<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">¿</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Medio&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">44&#46;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">50&nbsp;\t\t\t\t\t\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&#46;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="" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bajo&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">26&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;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">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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Distribuci&#243;n bilobular &#40;&#37;&#41;</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="" valign="\n
                  \t\t\t\t\ttop\n
                  \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="" valign="\n
                  \t\t\t\t\ttop\n
                  \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="" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&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">31&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;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">72&#46;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">0&#46;000<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">¿</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 ; entry_with_role_rowhead " 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">68&#46;8&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
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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">27&#46;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="" 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></tbody></table>
                  """
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        "tipo" => "MULTIMEDIATABLA"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Morbilidad arterial &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Morbilidad biliar &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">35&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">¿</span></a>&nbsp;\t\t\t\t\t\t\n
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