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dos quais 4&#46;200 em homens e 4&#46;250 em mulheres&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a> Os coeficientes de morbidade do melanoma atingem 51&#44;7 casos por 100&#46;000 habitantes na Austr&#225;lia&#44; considerada uma das taxas mais altas do mundo&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Na regi&#227;o Sul do Brasil&#44; o c&#226;ncer de pele melanoma &#233; mais incidente quando comparado com as demais regi&#245;es&#44; para ambos os sexos&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">6&#44;7</span></a> As taxas de incid&#234;ncia anual do melanoma por 100&#46;000 habitantes estimadas nas capitais do Sul do Brasil em 2019 pelo Instituto Nacional de C&#226;ncer &#40;INCA&#41; foram de 8&#44;3 e 7&#44;39 em Curitiba&#47;PR&#59; 6&#44;84 e 7&#44;94 em Florian&#243;polis&#47;SC e 9&#44;25 e 10&#44;12 em Porto Alegre&#47;RS para homens e mulheres&#44; respectivamente &#8211; taxas comprovadamente subestimadas em rela&#231;&#227;o a Blumenau&#47;SC&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">6&#8211;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">No Brasil&#44; dados sobre coeficiente de incid&#234;ncia do melanoma cut&#226;neo s&#227;o raros e muito subestimados em munic&#237;pios&#44; capitais&#44; estados e no pr&#243;prio pa&#237;s&#44; demonstrando a necessidade de estudos epidemiol&#243;gicos espec&#237;ficos&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A cidade de Blumenau est&#225; localizada no nordeste do estado de Santa Catarina&#44; latitude 26&#176;55&#8217;10&#8221; Sul&#44; longitude 49&#176;03&#8217;58&#8221;&#44; a 21 metros do n&#237;vel do mar&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> A popula&#231;&#227;o caucasiana&#44; formada em sua maioria por descendentes de alem&#227;es e italianos&#44; com fototipos I e II de acordo com a classifica&#231;&#227;o de Fitzpatrick&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> est&#225; sujeita a intensa radia&#231;&#227;o no ver&#227;o&#44; com &#237;ndice de radia&#231;&#227;o ultravioleta B &#40;UVB&#41; entre 11&#44;5 e 13&#44;0 conforme o Instituto Nacional de Pesquisas Espaciais &#40;INPE&#41; e muito alto de acordo com a Environonmental Protection Agency&#47;Operational Satellites &#40;EPA&#47;NOOA&#41; dos Estados Unidos &#8211; portanto&#44; exposta aos principais fatores de risco do melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">O objetivo deste estudo retrospectivo de 40 anos &#40;1980&#8208;2009<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> mais 2010&#8208;2019&#41; &#233; descrever as caracter&#237;sticas epidemiol&#243;gicas do melanoma cut&#226;neo na cidade de Blumenau&#44; apresentando dados estat&#237;sticos que poder&#227;o servir de refer&#234;ncia para estudos epidemiol&#243;gicos e preven&#231;&#227;o da doen&#231;a no Sul do Brasil&#46; A longevidade deste trabalho possibilita mostrar o impacto das a&#231;&#245;es da educa&#231;&#227;o sanit&#225;ria na preven&#231;&#227;o e no tratamento precoce do melanoma cut&#226;neo&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="par0035" class="elsevierStylePara elsevierViewall">Este &#233; um estudo retrospectivo&#44; descritivo e transversal que coletou 2&#46;336 casos de melanoma cut&#226;neo prim&#225;rio nos tr&#234;s &#250;nicos laborat&#243;rios de anatomia patol&#243;gica existentes na cidade&#44; CIPAC &#40;Laborat&#243;rio de Citologia&#44; Imunopatologia e Anatomia Patol&#243;gica &#8208; entre 1980 e 2019&#41;&#44; BML &#40;Laborat&#243;rio Beatriz Moreira Leite&#41; e Pathology Diagn&#243;stico em Medicina&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Os dados coletados em protocolo pelos autores inclu&#237;am caracter&#237;sticas dos pacientes &#40;idade&#44; sexo&#44; localiza&#231;&#227;o do tumor&#41; e aspectos histopatol&#243;gicos do melanoma&#46; Como crit&#233;rios de inclus&#227;o e exclus&#227;o na revis&#227;o dos casos&#44; foram considerados apenas pacientes provenientes do munic&#237;pio de Blumenau e exclu&#237;dos casos de pacientes residentes em outros munic&#237;pios&#44; para a fidelidade dos c&#225;lculos dos coeficientes de morbidade&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">As taxas de incid&#234;ncia de melanoma cut&#226;neo por 100&#46;000 habitantes para a cidade de Blumenau foram calculadas com base na popula&#231;&#227;o anual entre 1980 e 2019 estimadas pelo Instituto Brasileiro de Geografia e Estat&#237;stica &#40;IBGE&#41;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> e casos encontrados anualmente&#44; para que pudessem ser comparadas com os coeficientes de outras cidades&#44; estados e pa&#237;ses&#46; Os dados foram digitados e calculados no programa Excel vers&#227;o 2016&#44; somando dados de 2010 a 2019 com os publicados de 1980 a 2009 nos <span class="elsevierStyleItalic">Anais Brasileiros de Dermatologia</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> Foram utilizados testes Qui&#8208;Quadrado&#44; teste de Mann&#8208;Whitney&#44; teste de Kruskal Wallis &#40;teste n&#227;o param&#233;trico&#41;&#44; teste de Dun e correla&#231;&#227;o de Spearman&#46; A pesquisa foi aprovada pelo Comit&#234; de &#201;tica em Experimentos em Seres Humanos da Universidade Regional de Blumenau&#44; conforme Certificado de Apresenta&#231;&#227;o de Aprecia&#231;&#227;o &#201;tica &#40;CAAE&#41; 42905821&#46;2&#46;0000&#46;5370 e Parecer Consubstanciado do Comit&#234; de &#201;tica n&#176; 4&#46;580&#46;124&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">O total de casos de melanoma cut&#226;neo prim&#225;rio entre 1980 e 2019 foi de 2&#46;336&#44; dos quais 44&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;078&#41; ocorreram em pacientes do sexo masculino e 56&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;258&#41; em pacientes do sexo feminino&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a> mostra as taxas anuais de incid&#234;ncia geral e por sexo do melanoma cut&#226;neo prim&#225;rio no munic&#237;pio de Blumenau entre 1980 e 2019&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> Ressaltamos as taxas de incid&#234;ncia gerais de 42&#44;2 &#40;2011&#41; e 44&#44;26 &#40;2018&#41; casos por 100&#46;000 habitantes&#47;ano de melanoma cut&#226;neo prim&#225;rio e de 52&#44;87 &#40;2011&#41; e 41&#44;7 &#40;2018&#41;&#47;100&#46;000 habitantes no sexo masculino &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46; As taxas de incid&#234;ncia no sexo feminino foram de 46&#44;7&#47;100&#46;000 habitantes em 2018 e 44 em 2013 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a> apresenta a m&#233;dia das taxas de incid&#234;ncia por grupos de anos&#44; com signific&#226;ncia no per&#237;odo de 2000 a 2004&#44; cuja incid&#234;ncia de melanoma cut&#226;neo foi significantemente maior no sexo feminino &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0279&#41;&#46; Nos demais per&#237;odos&#44; n&#227;o houve signific&#226;ncia&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">A faixa et&#225;ria de maior incid&#234;ncia foi acima de 55 anos&#44; com 57&#37; dos casos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;321&#41;&#59; abaixo de 39 anos&#44; foram 14&#44;9&#37; dos casos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>343&#41;&#44; com 95&#37; de confian&#231;a &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Na <a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a>&#44; a fim de verificar o aumento do coeficiente de incid&#234;ncia em cada per&#237;odo e ao longo das faixas et&#225;rias&#44; foi utilizado o teste de Mann&#8208;Whitney e a correla&#231;&#227;o de Spearman&#46; Ambas as t&#233;cnicas pertencem &#224; estat&#237;stica n&#227;o param&#233;trica&#46; Justifica&#8208;se a utiliza&#231;&#227;o de tal estat&#237;stica considerando&#8208;se a rejei&#231;&#227;o da hip&#243;tese nula do teste de normalidade &#40;teste de Shapiro&#8208;Wilk&#41; &#8211; ou seja&#44; segundo o teste de normalidade realizado&#44; os dados n&#227;o aderem a um modelo de distribui&#231;&#227;o normal&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Como resultado dessa parte inferencial&#44; tem&#8208;se que tanto nos homens quanto nas mulheres o coeficiente de incid&#234;ncia teve aumento significativo de 1980 para 2018&#46; Por outro lado&#44; apresentou correla&#231;&#227;o muito forte nos anos de 2008 e 2018&#44; o que indica maior concentra&#231;&#227;o do n&#250;mero de casos nas faixas et&#225;rias mais avan&#231;adas&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Em 2018&#44; a taxa de incid&#234;ncia no sexo masculino atingiu 253 casos&#47;100&#46;000 habitantes&#47;ano na faixa et&#225;ria de 65&#8208;69 anos e 421 casos por 100&#46;000 habitantes na faixa et&#225;ria &#8805; 70 anos&#46; No sexo feminino&#44; no mesmo ano&#44; encontramos 128 casos&#47;100&#46;000 habitantes&#47;ano na faixa et&#225;ria de 65&#8208;69 anos&#44; e 301 casos na faixa &#8805; 70 anos &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a>&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0025">tabela 5</a> apresenta os tipos histol&#243;gicos mais frequentes&#58; melanoma disseminativo superficial&#44; com 64&#44;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>996&#41; entre 1980 e 2019&#44; seguido pelo melanoma nodular com 22&#44;8&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>353&#41;&#46; Os lentigos malignos melanoma atingiram 9&#44;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>143&#41;&#44; e o melanoma acrolentiginoso&#44; 3&#44;3&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>51&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A distribui&#231;&#227;o do tipo histol&#243;gico segundo o sexo mostrou predomin&#226;ncia de 68&#44;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>569&#41; do tipo disseminativo superficial nas mulheres &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00050&#41; e 60&#37; nos homens &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabela 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0030">tabela 6</a> mostra a distribui&#231;&#227;o num&#233;rica e percentual do melanoma cut&#226;neo segundo localiza&#231;&#227;o prim&#225;ria e sexo&#44; com predomin&#226;ncia de 49&#44;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>366&#41; de localiza&#231;&#227;o prim&#225;ria no tronco dos homens &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; e de 35&#44;3 &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>267&#41; no das mulheres&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0035">tabela 7</a> apresenta a distribui&#231;&#227;o percentual dos casos de melanoma de acordo com o n&#237;vel de Clark entre 1980 e 1999&#44; 2000 a 2009 e 2010 a 2019&#44; destacando o aumento percentual dos diagn&#243;sticos precoces &#40;n&#237;veis I e II de Clark&#41; de 24&#44;95&#37; entre 1980&#8208;1990 para 49&#44;8&#37; de 2010 a 2019&#46; Significa aumento de 199&#44;6&#37; nos diagn&#243;sticos precoces no per&#237;odo de 2010 a 2019 em compara&#231;&#227;o ao per&#237;odo de 1980 a 1990&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> Entre os anos de 2010 a 2019&#44; houve aumento significante do n&#250;mero de casos de melanoma nos n&#237;veis de Clark I e II e no n&#237;vel V&#44; de acordo com o teste Qui&#8208;quadrado&#46; Pode&#8208;se observar melhor esse aumento na <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#46;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0040">tabela 8</a> mostra a distribui&#231;&#227;o percentual dos melanomas de acordo com o &#237;ndice de espessura de Breslow entre 1995 e 1999&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> 2000 e 2009<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> e de 2010 a 2019&#46; Os melanomas diagnosticados com espessura &#60;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm atingiram 46&#44;7&#37; entre 1995 e 1999<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> e aumentaram para 63&#37; entre 2000 e 2009&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> chegando a 58&#37; entre 2010 a 2019 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;000001&#41;&#46;</p><elsevierMultimedia ident="tbl0040"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">No &#250;ltimo per&#237;odo &#40;2010&#8208;2019&#41; houve aumento significante do percentual do melanoma cut&#226;neo nas categorias de espessura de 0&#44;0 a 0&#44;5<span class="elsevierStyleHsp" style=""></span>mm e &#62;<span class="elsevierStyleHsp" style=""></span>2&#44;0<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Houve aumento de 134&#37; da frequ&#234;ncia na espessura de Breslow entre 0&#8208;1<span class="elsevierStyleHsp" style=""></span>mm &#40;diagn&#243;stico precoce&#41; no per&#237;odo de 2000 e 2008<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> em rela&#231;&#227;o ao per&#237;odo de 1995 a 1999 e de 1918&#37; de melanoma &#40;<span class="elsevierStyleItalic">in situ</span>&#41; &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>mm em 2010 a 2019 &#40;518 casos&#41; em rela&#231;&#227;o a 1995&#8208;1999 &#40;27 casos&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;000001&#41;&#46; A <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a> ilustra esse aumento significante do n&#250;mero percentual de casos&#44; evidenciado pelo teste Qui&#8208;Quadrado&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discuss&#227;o</span><p id="par0120" class="elsevierStylePara elsevierViewall">Esta pesquisa abrange apenas exames histopatol&#243;gicos com diagn&#243;sticos definitivos de melanoma cut&#226;neo prim&#225;rio&#59; portanto&#44; os dados s&#227;o subestimados&#44; resultando consequentemente em taxas menores que a realidade&#44; por&#233;m altas em rela&#231;&#227;o &#224;s taxas de incid&#234;ncia encontradas no Brasil e no mundo&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">O estudo mostra que a morbidade do melanoma cut&#226;neo em Blumenau aumentou de 4&#44;4 &#40;1980&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> para 44&#44;26 casos por 100&#46;000 habitantes &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#44; com crescimento brutal da incid&#234;ncia&#44; cerca de 1000&#37; na morbidade por 100&#46;000 habitantes em rela&#231;&#227;o a 1980&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">As taxas ajustadas para a popula&#231;&#227;o mundiais encontradas foram de 25&#44;86 casos de melanoma por 100&#46;000 habitantes&#47;ano baseadas em casos diagnosticados entre 1975&#8208;2017 originadas de 17 &#225;reas geogr&#225;ficas do SEER&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Como n&#227;o foi realizada a incid&#234;ncia por idade &#40;SEER&#41;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> e como nas &#250;ltimas d&#233;cadas houve ganho na expectativa de vida&#44; parte do aumento dos diagn&#243;sticos pode ser explicado em fun&#231;&#227;o da extens&#227;o da sobrevida do grupo de idosos de maior risco&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Os coeficientes de morbidade de melanoma cut&#226;neo encontrados em Blumenau est&#227;o pr&#243;ximos dos esperados para os descendentes de europeus &#40;alem&#227;es e italianos&#41;&#44; caucasianos de pele clara vivendo em regi&#227;o geogr&#225;fica com alto &#237;ndice de radia&#231;&#227;o UV&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">1&#44;3&#44;12</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Sexo</span><p id="par0145" class="elsevierStylePara elsevierViewall">Na popula&#231;&#227;o mundial&#44; a incid&#234;ncia do melanoma cut&#226;neo no sexo feminino subiu de 8&#44;20<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> em 1980 para 26&#44;4 casos por 100&#46;000 habitantes em 2017&#59; no sexo masculino&#44; aumentou de 9&#44;44 em 1980<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> para 33&#44;31 por 100&#46;000 habitantes em 2017 &#8211; taxas ajustadas para o padr&#227;o mundial&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Na Inglaterra&#44; a taxa de incid&#234;ncia ajustada para padr&#227;o mundial atingiu nas mulheres 24&#44;5 casos por 100&#46;000 habitantes em 2017 e nos homens 28&#44;8 casos no mesmo ano&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Na Alemanha&#44; com popula&#231;&#227;o caucasiana como a encontrada em Blumenau&#44; os coeficientes de morbidade encontrados em Northrhine&#8208;Westphalia foram de 13&#44;6 casos por 100&#46;000 habitantes nos homens e de 18&#44;5 nas mulheres&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">No Brasil existe maior mortalidade nos homens&#44; provavelmente em decorr&#234;ncia do diagn&#243;stico tardio&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a> Em Blumenau&#44; entre 1980 e 2019&#44; foram estudados 2&#46;336 casos de melanoma cut&#226;neo prim&#225;rio&#44; dos quais 1&#46;078 do sexo masculino &#40;46&#37;&#41; e 1&#46;258 do sexo feminino &#40;54&#37;&#41;&#46; A taxa de incid&#234;ncia mais alta no sexo feminino atingiu 46&#44;73 casos&#47;100&#46;000 habitantes em 2018&#44; e no sexo masculino foram registrados 52&#44;87 casos&#47;100&#46;000 habitantes &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Observa&#8208;se predomin&#226;ncia significante da incid&#234;ncia no sexo feminino a partir do ano 2000 em decorr&#234;ncia da maior sobrevida feminina nesse per&#237;odo&#46; A predomin&#226;ncia feminina aparece clara na <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#44; e pode ser considerada consequ&#234;ncia de maior aten&#231;&#227;o &#224;s campanhas de esclarecimentos para diagn&#243;sticos precoces e maior cuidado com a sa&#250;de das mulheres&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Grupo et&#225;rio</span><p id="par0170" class="elsevierStylePara elsevierViewall">O melanoma cut&#226;neo causa mais mortes do que qualquer outro tumor cut&#226;neo&#44; e as taxas de incid&#234;ncia e mortalidade t&#234;m aumentado nos &#250;ltimos anos&#44; principalmente em pacientes com idade avan&#231;ada&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">15&#44;16</span></a> De 1992 a 2006&#44; as taxas de incid&#234;ncia de melanoma entre brancos n&#227;o hisp&#226;nicos aumentaram para todas as idades&#46; As taxas de mortalidade aumentaram para pessoas mais velhas &#40;&#62; 65 anos&#41;&#44; mas n&#227;o para pessoas mais jovens&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Nos Estados Unidos&#44; h&#225; predomin&#226;ncia da taxa de incid&#234;ncia do melanoma cut&#226;neo no grupo et&#225;rio acima de 55 anos&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a> A incid&#234;ncia do melanoma no Reino Unido e nos Estados Unidos entre 1973 e 2002 aumentou em todos os grupos et&#225;rios&#44; tanto em homens quanto em mulheres&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Nos Estados Unidos&#44; homens entre 55&#8208;64 anos tiveram aumento de 12&#44;4 para 56&#44;1 casos&#47;100&#46;000 habitantes&#44; e aqueles acima de 65 anos tiveram aumento de 18&#44;8 para 104&#44;4&#47;100&#46;000 habitantes&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Neste estudo&#44; houve incid&#234;ncia percentual de 57&#44;65&#37; de melanomas no grupo acima de 54 anos no per&#237;odo de 1980&#8208;2019 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41; e de 14&#44;9&#37; na faixa et&#225;ria menor de 39 anos&#46; As taxas de incid&#234;ncia bruta por 100&#46;000 habitantes e por faixa et&#225;ria e sexo nos anos de 1980&#44; 2008 e 2018 encontradas em Blumenau mostraram altos coeficientes de morbidade nos grupos et&#225;rios acima de 50 anos&#46; A taxa de incid&#234;ncia na faixa et&#225;ria de 65&#8208;69 anos foi de 106 casos por 100&#46;000 habitantes no sexo masculino em 2008 e 253 casos&#47;100&#46;000 habitantes em 2018&#46; No sexo feminino&#44; na faixa et&#225;ria de 65&#8208;69 foi de 77&#44;2 em 2008 e 128&#44;7 casos por 100&#46;000 habitantes em 2018&#46; Nas pessoas &#8805; 70 anos o coeficiente de morbidade por 100&#46;000 habitantes chegou a 421 casos nos homens e 301 casos nas mulheres em 2018 &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a>&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a> mostra tamb&#233;m as medias de incid&#234;ncia nos anos estudados e todos os testes de confian&#231;a&#44; de desvio padr&#227;o e de correla&#231;&#227;o para tornar mais fidedignos os dados relatados&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">A alta incid&#234;ncia do melanoma cut&#226;neo est&#225; fortemente relacionada &#224; idade&#44; com as taxas de incid&#234;ncia espec&#237;ficas por idade aumentando acentuadamente de 50 anos para o pico em pessoas com mais de 75 anos&#46; Essa alta incid&#234;ncia sugere programas de preven&#231;&#227;o mais apurados e efetivos para essa faixa et&#225;ria no munic&#237;pio e em outras regi&#245;es com popula&#231;&#227;o caucasiana semelhante &#224; de Blumenau&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Localiza&#231;&#227;o prim&#225;ria</span><p id="par0200" class="elsevierStylePara elsevierViewall">No Canad&#225;&#44; em 2019&#44; um estudo de 50 anos mostrou que a localiza&#231;&#227;o mais frequente foi no t&#243;rax &#40;&#225;rea coberta&#41; principalmente em homens&#44; e a localiza&#231;&#227;o nos membros inferiores &#233; mais comum nas mulheres&#46; O mesmo ocorre nos Estados Unidos&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Em Blumenau&#44; a localiza&#231;&#227;o prim&#225;ria do melanoma cut&#226;neo prim&#225;rio mais comum em 42&#44;3&#37; dos casos foi no tronco &#40;57&#44;8&#37; nos homens e 42&#44;2&#37; nas mulheres&#41;&#46; Nos membros inferiores&#44; a incid&#234;ncia foi mais comum nas mulheres &#40;63&#44;9&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00001&#41;&#44; enquanto entre os homens foi de 36&#44;1&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">tabela 6</a>&#41;&#46; Podemos relacionar esses dados com o uso de saias pelas mulheres e cal&#231;as compridas pelos homens&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Histopatologia</span><p id="par0210" class="elsevierStylePara elsevierViewall">Num estudo de 771 casos revistos de melanoma no Texas e na Calif&#243;rnia&#44; o melanoma lentigo maligno foi o mais frequente&#44; com 56&#37; dos casos e com 29&#37; de melanoma disseminativo superficial&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">19&#44;20</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Em Blumenau&#44; entre 1980 e 2019&#44; o melanoma disseminativo superficial foi o mais frequente &#40;64&#44;5&#37;&#41;&#44; com 68&#44;5&#37; no sexo feminino &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00050&#41; e 60&#37; no sexo masculino&#46; O segundo tipo histol&#243;gico mais comum foi melanoma nodular &#40;22&#44;8&#37;&#41;&#44; seguido do melanoma lentigo maligno &#40;9&#44;4&#37;&#41; e o acrolentiginoso &#40;3&#44;3&#37;&#41; &#8211; <a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a>&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">O melanoma nodular aparece em todos os estudos com maior mortalidade em decorr&#234;ncia do n&#237;vel de invas&#227;o mais avan&#231;ados&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">19&#8211;21</span></a> O estadiamento do diagn&#243;stico n&#227;o &#233; poss&#237;vel realizar porque o estudo baseou&#8208;se apenas em laudos histopatol&#243;gicos&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">N&#237;vel de invas&#227;o</span><p id="par0225" class="elsevierStylePara elsevierViewall">A sobrevida do paciente depende da espessura e do n&#237;vel de invas&#227;o do melanoma cut&#226;neo prim&#225;rio e sua redu&#231;&#227;o encontrada nos exames histopatol&#243;gicos equivalem ao diagn&#243;stico precoce e &#224; melhora da sobrevida&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">21&#44;22</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Pacientes com melanoma cut&#226;neo prim&#225;rio com espessura de Breslow &#60;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm s&#227;o considerados de baixo risco e com excelente progn&#243;stico de sobrevida&#44; podendo levar a mortalidade a zero&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">21&#44;22</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Em Blumenau&#44; no per&#237;odo de 1980 a 1990&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> 25&#37; dos diagnosticados com melanoma cut&#226;neo prim&#225;rio eram dos n&#237;veis I e II de Clark&#44; e entre 2010&#8208;2019 esse percentual passou a ser de 49&#44;8&#37; dos casos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00001&#41;&#44; com aumento de 199&#37;&#44; com poss&#237;vel melhora da sobrevida &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">tabela 7</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">10&#44;21&#44;22</span></a> A <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> mostra claramente o n&#250;mero de diagn&#243;sticos precoces representados pelos n&#237;veis I e II de Clark&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">De 2000 a 2009&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> conforme espessura de Breslow&#44; a porcentagem de diagn&#243;stico precoce foi de 62&#44;5&#37; para os melanomas &#60;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm&#44; e de 2010 a 2019 foi de 52&#44;85&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0040">tabela 8</a>&#41;&#46; Valor semelhante foi relatado nos EUA&#44; onde 66&#37; de todos os melanomas diagnosticados entre 1988 e 1999 apresentaram espessura de Breslow &#60;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">22&#8208;24</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Este estudo mostra&#44; ent&#227;o&#44; que houve aumento dos diagn&#243;sticos precoces comparando os dados dos &#237;ndices de Breslow no per&#237;odo de 2000 a 2009<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> e 2010 a 2019 com os dados do per&#237;odo de 1995 a 1999<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0040">tabela 8</a>&#41;&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Analisando as tabelas 7 e 8&#44; notamos que os melanomas finos &#40;&#60; 1<span class="elsevierStyleHsp" style=""></span>mm Breslow e n&#237;veis I e II de Clark&#41; encontrados podem indicar maior sobrevida dos pacientes com melanoma maligno&#44; a qual &#233; inversamente proporcional &#224; espessura do tumor&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">21&#44;22</span></a> Considerando os melanomas &#8220;finos&#8221;&#44; verifica&#8208;se aumento da poss&#237;vel melhora da sobrevida de 199&#37; de acordo com o n&#237;vel de Clark &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">tabela 7</a>&#41; em 2019 em rela&#231;&#227;o a 1980&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> e de 113&#37; de sobrevida segundo espessura de Breslow na d&#233;cada de 2010&#8208;2019 em rela&#231;&#227;o a 1995&#8208;1999<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0040">tabela 8</a>&#41;&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Os diagn&#243;sticos de melanomas <span class="elsevierStyleItalic">in situ</span> &#40;0&#8208;0&#44;5 mm&#41; aumentaram cerca de 1900&#37; no per&#237;odo de 2010&#8208;2019 &#40;518 casos&#41; em rela&#231;&#227;o a 1995&#8208;1999 &#40;27 casos&#41;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;000001&#46; Esses dados s&#227;o evidenciados na <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a>&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">O aumento dos melanomas invasivos &#40;&#62; 2 mm&#41; pode ser decorrente do incremento da sobrevida populacional no munic&#237;pio&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">A taxa de letalidade representada pelos melanomas &#8220;espessos&#8221; pode ter diminu&#237;do em 65&#37; comparando as porcentagens entre 1980&#8208;1990<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> com a d&#233;cada de 2010&#8208;2019&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">A diminui&#231;&#227;o da espessura do melanoma cut&#226;neo nos diagn&#243;sticos histopatol&#243;gicos pode ser creditada a campanhas de educa&#231;&#227;o da popula&#231;&#227;o para a preven&#231;&#227;o e treinamento dos profissionais de sa&#250;de para diagn&#243;stico e tratamento precoces e o uso da dermatoscopia pelos dermatologistas&#46; Essa evid&#234;ncia &#233; demonstrada e permitida neste estudo de 40 anos&#44; que controlou e comparou os n&#237;veis de invas&#227;o e os coeficientes de morbidade&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">21&#8208;25</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclus&#245;es</span><p id="par0275" class="elsevierStylePara elsevierViewall">Os resultados encontrados neste estudo podem servir como refer&#234;ncia para a maioria dos munic&#237;pios do Sul do Brasil&#44; onde h&#225; intensa radia&#231;&#227;o solar atingindo a popula&#231;&#227;o de pele clara&#44; fototipos I e II&#44; descendentes de europeus&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">O aumento do diagn&#243;stico precoce pode ser creditado &#224;s campanhas de educa&#231;&#227;o e preven&#231;&#227;o prim&#225;ria relatada em outros pa&#237;ses<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">22&#8208;25</span></a> e realizado no Brasil pela Sociedade Brasileira de Dermatologia&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Este estudo epidemiol&#243;gico de 40 anos conclui com as seguintes observa&#231;&#245;es&#58;</p><p id="par0290" class="elsevierStylePara elsevierViewall">De 1980 a 2019&#44; a taxa bruta do melanoma aumentou de 4&#44;4 casos<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> para 44&#44;26&#47;100&#46;000 habitantes&#44; com pico de 46&#44;73 nas mulheres e de 52&#44;87 nos homens e predomin&#226;ncia de incid&#234;ncia do melanoma no sexo feminino com 56&#37; dos casos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;258&#41;&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Houve maior incid&#234;ncia do melanoma no grupo et&#225;rio<span class="elsevierStyleHsp" style=""></span>&#62; 50 anos &#40;64&#44;9&#37;&#41;&#44; com pico &#8805; 70 anos com 421&#44;6 casos por 100&#46;000 habitantes homens e 301 casos nas mulheres &#40;2018&#41;&#46; Predominaram os tipos histol&#243;gicos disseminativo superficial&#44; com 64&#44;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>996&#41;&#44; seguido do melanoma nodular&#44; com 22&#44;8&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>353&#41;&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">Houve aumento do diagn&#243;stico precoce no per&#237;odo de 2000&#8208;2009&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> representado por 63&#37; dos diagn&#243;sticos com espessura de Breslow &#60;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm&#44; e 53&#37; no per&#237;odo de 2010&#8208;2019&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">Verificou&#8208;se tamb&#233;m poss&#237;vel aumento da sobrevida<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">21&#8208;25</span></a> de 199&#37; de acordo com n&#237;vel de Clark em 2010&#8208;2019 em rela&#231;&#227;o a 1980&#8208;1990<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> e de 113&#37; de sobrevida segundo espessura de Breslow na d&#233;cada de 2010&#8208;2019 em rela&#231;&#227;o a 1995&#8208;1999&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">A taxa de letalidade representada pelos melanomas espessos diminuiu de 75&#37; dos casos entre 1980&#8208;1990<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> para 49&#37; na d&#233;cada de 2010&#8208;2019&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">19&#44;20</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">Diante do aumento da incid&#234;ncia principalmente em idosos&#44; &#233; essencial que se mantenham campanhas de conscientiza&#231;&#227;o p&#250;blica dos sinais iniciais do melanoma&#44; a regra do ABCDE&#44; aten&#231;&#227;o para os familiares&#44; m&#250;ltiplos nevus e atendimento priorit&#225;rio aos idosos&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Suporte financeiro</span><p id="par0320" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Contribui&#231;&#227;o dos autores</span><p id="par0325" class="elsevierStylePara elsevierViewall">Nilton Nasser&#58; Concep&#231;&#227;o e desenho do estudo&#59; levantamento de dados&#59; reda&#231;&#227;o do artigo e revis&#227;o cr&#237;tica do conte&#250;do&#59; elabora&#231;&#227;o das tabelas&#44; nos anos de 1980 a 2019&#59; aprova&#231;&#227;o final do manuscrito&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Joana Laurindo da Silva&#58; Coleta de dados&#44; aspectos legais do estudo&#44; como aprova&#231;&#227;o do Comit&#234; de &#201;tica&#44; levantamento bibliogr&#225;fico&#59; ajuda na elabora&#231;&#227;o das tabelas&#59; aprova&#231;&#227;o final do manuscrito&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">Grazielle Corr&#234;a&#58; Coleta de dados&#44; levantamento de dados&#59; ajuda na elabora&#231;&#227;o das tabelas&#59; aprova&#231;&#227;o final do manuscrito&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflito de interesses</span><p id="par0340" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Fundamentos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A incid&#234;ncia e a mortalidade do melanoma aumentaram nos &#250;ltimos anos na popula&#231;&#227;o caucasiana&#46; Este estudo de 40 anos descreve a incid&#234;ncia do melanoma em Blumenau &#40;SC&#44; Brasil&#41; e mostra o impacto da preven&#231;&#227;o prim&#225;ria na redu&#231;&#227;o da mortalidade&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Avaliar a incid&#234;ncia e classificar melanomas cut&#226;neos na cidade de Blumenau no per&#237;odo de 1980 a 2019&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Este estudo retrospectivo&#44; descritivo e transversal coletou 2&#46;336 exames histopatol&#243;gicos de indiv&#237;duos moradores da cidade de Blumenau&#44; considerando sexo&#44; idade&#44; localiza&#231;&#227;o prim&#225;ria&#44; tipo histopatol&#243;gico&#44; n&#237;vel de invas&#227;o e espessura tumoral&#46; Os coeficientes de incid&#234;ncias anuais foram calculados utilizando o n&#250;mero de melanomas e a popula&#231;&#227;o estimada pelo Instituto Brasileiro de Geografia e Estat&#237;sticas entre os anos de 1980 e 2019&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">As taxas de incid&#234;ncia do melanoma atingiram 44&#44;26 casos&#47;100&#46;000 habitantes&#47;ano&#44; e por sexo chegou a 52&#44;87 em homens e 46&#44;73 casos em mulheres por 100&#46;000 habitantes&#46; A faixa et&#225;ria mais afetada foi &#8805; 70 anos&#44; com 421 casos para homens e 301 casos para mulheres por 100&#46;000 habitantes&#46; O melanoma extensivo superficial foi o mais frequente&#44; com 64&#44;5&#37; dos casos&#44; seguido do melanoma nodular&#44; com 22&#44;8&#37;&#46; Os diagn&#243;sticos precoces atingiram 1900&#37;&#44; com Breslow &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5 mm&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Limita&#231;&#245;es do estudo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Esta pesquisa abrange apenas exames histopatol&#243;gicos com diagn&#243;stico definitivo de melanoma cut&#226;neo&#59; portanto&#44; os dados s&#227;o subestimados&#44; resultando&#44; consequentemente&#44; em taxas menores que na realidade&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#245;es</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A incid&#234;ncia do melanoma cut&#226;neo aumentou em cinco vezes entre os anos de 1980 e 2019&#44; e o diagn&#243;stico precoce aumentou em rela&#231;&#227;o a 1980 como resultado da educa&#231;&#227;o sanit&#225;ria da popula&#231;&#227;o e preven&#231;&#227;o prim&#225;ria&#46;</p></span>"
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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="\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">Ano&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">Masculino&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">Feminino&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">Geral&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">Ano&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">Masculino&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">Feminino&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">Geral&nbsp;\t\t\t\t\t\t\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">1980&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">5&#44;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">3&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">4&#44;4</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">2000&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">13&#44;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">13&#44;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">13&#44;45&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">1981&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">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">10&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;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">23&#44;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">19&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">1982&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">11&#44;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">8&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2002&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">12&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">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">1983&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">11&#44;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">10&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&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">2003&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">13&#44;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">17&#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">15&#44;45&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">1984&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&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;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">6&#44;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">2004&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">13&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#44;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">16&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">1985&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">13&#44;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">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;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">2005&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">13&#44;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">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">1986&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44;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">8&#44;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">2006&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">15&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">15&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#44;35&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">1987&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">10&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;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">11&#44;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">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;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">31&#44;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">23&#44;15&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">1988&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">7&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2008&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">18&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">23&#44;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">20&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">1989&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">15&#44;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">12&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#44;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">2009&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&#44;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">20&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#44;2&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">1990&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&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&#44;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">18&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&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">36&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#44;31&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">37&#44;83&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">1991&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;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">12&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">12&#44;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">2011&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&#44;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#44;2&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">1992&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;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">10&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#44;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">2012&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">41&#44;31&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">39&#44;07&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">40&#44;17&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">1993&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#44;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">17&#44;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">15&#44;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">2013&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">35&#44;34&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">44&#44;09&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">39&#44;8&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">1994&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">15&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">11&#44;36&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">9&#44;79&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">2014&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">37&#44;27&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">44&#44;02&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">40&#44;71&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">1995&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&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">18&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;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">2015&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">35&#44;53&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">43&#44;39&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">39&#44;54&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">1996&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#44;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">17&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;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">2016&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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#44;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#44;34&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">1997&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&#44;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">3&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&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">41&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">39&#44;94&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">39&#44;88&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">1998&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">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#44;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">13&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&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">41&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#44;73&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">44&#44;26&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">1999&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#44;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">17&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;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">2019&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">33&#44;13&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">40&#44;62&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">39&#44;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Fonte&#58; Instituto Brasileiro de Geografia e Estat&#237;stica &#40;IBGE&#41;&#44; Laborat&#243;rio de Citologia&#44; Imunopatologia e Anatomia Patol&#243;gica &#40;CIPAC&#41;&#44; Pathology Diagn&#243;stico em Medicina e Beatriz Moreira Leite &#40;BML&#41; Patologia &#40;anos 1980 a 1990&#41;&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">&#42; Por100&#46;000&#47;habitantes&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">p&#44; Valor&#8208;p do Teste de Mann&#8208;Whitney &#40;teste n&#227;o param&#233;trico&#44; compara duas amostras independentes&#41;&#46;</p>"
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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-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#40;M&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#40;M&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&#40;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;24&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;7&#44;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;09&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;7&#44;87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;99&#41;&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&#44;9000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;11&#44;04<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;26&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;11&#44;02<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;11&#44;03<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;09&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;17&#44;76<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;13&#44;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;22&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;15&#44;76<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;13&#41;&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&#44;1313&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&#40;14&#44;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;16&#44;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;4&#41;&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&#44;4720&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">2000 a 2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;13&#44;36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;91&#41;&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">&#40;19&#44;44<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;11&#41;&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">&#40;16&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;0279</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2005 a 2009&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;22&#44;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;19&#44;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;55&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;1564&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#40;39&#44;68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;98&#41;&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">&#40;40&#44;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;87&#41;&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  " align="left" valign="\n
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                  \t\t\t\t">&#40;37&#44;87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;62&#41;&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">&#40;41&#44;87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;39&#44;87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;86&#41;&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">0&#44;1022&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1980 a 2019&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;20&#44;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;32&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;21&#44;32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;81&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;20&#44;93<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;49&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16&#44;6&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">165&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">343&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</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;13&#44;49&#8208;16&#44;41&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;23&#44;33&#8208;28&#44;59&#41;&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">353&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">28&#44;76&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">&#40;26&#44;24&#8208;31&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">630&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">27&#44;45&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">&#40;25&#44;64&#8208;29&#44;29&#41;&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
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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">253&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">23&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;21&#44;16&#8208;26&#44;26&#41;&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">288&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">23&#44;47&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">&#40;21&#44;1&#8208;25&#44;84&#41;&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">541&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">23&#44;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">&#40;21&#44;85&#8208;25&#44;32&#41;&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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#8208;70&#43;&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">359&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&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;30&#44;81&#8208;36&#44;48&#41;&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">421&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">34&#44;33&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">&#40;31&#44;65&#8208;36&#44;97&#41;&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">780&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">34&#44;15&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">&#40;32&#44;06&#8208;35&#44;94&#41;&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">TOTAL&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;067&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">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;227&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">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;294&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">100&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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          "pt" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Distribui&#231;&#227;o num&#233;rica e percentual do melanoma cut&#226;neo por faixa et&#225;ria&#44; e sexo &#8208; Blumenau&#8208;SC&#44; de 1980 a 2019</p>"
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Fonte&#58; Instituto Brasileiro de Geografia e Estat&#237;stica &#40;IBGE&#41;&#44; Laborat&#243;rio de Citologia&#44; Imunopatologia e Anatomia Patol&#243;gica &#40;CIPAC&#41;&#44; Pathology Diagn&#243;stico em Medicina e Beatriz Moreira Leite &#40;BML&#41; Patologia &#40;anos 1980 a 1990&#41;&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">I &#8211; DP&#44; desvio padr&#227;o&#59; DQ&#44; desvio quart&#237;lico&#46;</p><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">II &#8211; p&#44; Valor&#8208;p do Teste de Kruskal Wallis &#40;Teste n&#227;o param&#233;trico&#41;&#46; Letras diferentes representam diferen&#231;as significantes entre anos &#40;Teste de Dun&#41;&#46; Se p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#44; ent&#227;o diferen&#231;as significantes&#46;</p><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">III &#8211; <span class="elsevierStyleItalic">R</span>&#44; correla&#231;&#227;o de Spearman&#46; Homens&#58; R &#40;1980 e 2008&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#44;9&#37; e R &#40;2008 e 2018&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>97&#37;&#46; Mulheres&#58; R &#40;1980 e 2008&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>48&#44;6&#37; e R &#40;2008 e 2018&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>80&#44;9&#37;&#46; Total&#58; R &#40;1980 e 2008&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>57&#37; e R &#40;2008 e 2018&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>96&#44;7&#37;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Faixa et&#225;ria &#40;em anos&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Coefici&#234;ncia de incid&#234;ncia bruta 2018</th></tr><tr title="table-row"><th 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" 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">Masculino&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">Feminino&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">Total&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">Masculino&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">Feminino&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">Total&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">Masculino&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">Feminino&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">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#8208;19&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \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="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="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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="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="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></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">20&#8208;24&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="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="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="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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44;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">4&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="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="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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">569</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;00050</span>&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"><span class="elsevierStyleBold">197</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">156&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
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#44;88&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
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">TOTAL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">712&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">831&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&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">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  """
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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">Localiza&#231;&#227;o prim&#225;ria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Feminino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&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" scope="col" style="border-bottom: 2px solid black">&#37;&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">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">11&#44;37</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">127&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#44;49&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">Face&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12&#44;99&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">88&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
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                  \t\t\t\t">11&#44;62&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
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                  \t\t\t\t">184&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&#44;30&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\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">Tronco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">366</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"><span class="elsevierStyleBold">49&#44;53</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">267&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">35&#44;27&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">633&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#44;31&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"><span class="elsevierStyleBold">0&#44;00001</span>&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">Membros superiores&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">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">13&#44;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">191</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">25&#44;23</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">289&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">19&#44;32&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"><span class="elsevierStyleBold">0&#44;00001</span>&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">Membros inferiores&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">95&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">12&#44;86&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"><span class="elsevierStyleBold">168</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
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                  \t\t\t\t"><span class="elsevierStyleBold">22&#44;19</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">263&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&#44;58&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"><span class="elsevierStyleBold">0&#44;00001</span>&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">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">739&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">100&#44;00&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">757&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">100&#44;00&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">1496&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">100&#44;00&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>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3233278.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">Distribui&#231;&#227;o num&#233;rica e percentual do melanoma&#44; segundo localiza&#231;&#227;o prim&#225;ria e sexo&#44; em Blumenau&#8208;SC&#44; de 1980 a 2019</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "tbl0035"
        "etiqueta" => "Tabela 7"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at7"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">Fonte&#58; Laborat&#243;rio de Citologia&#44; Imunopatologia e Anatomia Patol&#243;gica &#40;CIPAC&#41;&#44; Pathology Diagn&#243;stico em Medicina e Beatriz Moreira Leite &#40;BML&#41; Patologia &#40;anos 1980&#8208;1990&#41;&#46;</p><p id="spar0160" class="elsevierStyleSimplePara elsevierViewall">p&#44; valor&#8208;p do teste Qui&#8208;quadrado de independ&#234;ncia&#46; Se p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#44; ent&#227;o associa&#231;&#227;o significante&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\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">Nivel de Clark&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">1980&#8208;1990&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">2000&#8208;2009&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">2010&#8208;2019&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">I&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">179 &#40;29&#37;&#41;&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">73 &#40;18&#37;&#41;&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">338 &#40;27&#44;5&#37;&#41;&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&#44;00001&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">II&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">120 &#40;20&#37;&#41;&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">114 &#40;27&#44;8&#37;&#41;&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">274 &#40;22&#44;3&#37;&#41;&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">III&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">63 &#40;10&#37;&#41;&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">76 &#40;18&#44;70&#37;&#41;&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">130 &#40;10&#44;57&#37;&#41;&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">IV&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">141 &#40;23&#37;&#41;&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 &#40;14&#44;20&#37;&#41;&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">152 &#40;12&#44;36&#37;&#41;&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">V&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">108 &#40;18&#37;&#41;&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">87 &#40;21&#44;30&#37;&#41;&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">335 &#40;27&#44;25&#37;&#41;&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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                0 => "xTab3233283.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">Distribui&#231;&#227;o percentual do melanoma maligno&#44; por d&#233;cadas&#44; de acordo com o n&#237;vel de Clark&#44; Blumenau &#40;SC&#41;</p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "tbl0040"
        "etiqueta" => "Tabela 8"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at8"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0170" class="elsevierStyleSimplePara elsevierViewall">Fonte&#58; Laborat&#243;rio de Citologia&#44; e Anatomia Patol&#243;gica &#40;CIPAC&#41; e Pathology Diagn&#243;stico em Medicina&#46;</p><p id="spar0175" class="elsevierStyleSimplePara elsevierViewall">p&#44; valor&#8208;p do teste Qui&#8208;Quadrado de independ&#234;ncia&#46; Se p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#44; ent&#227;o associa&#231;&#227;o significante&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\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">Espessura de Breslow&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">1995&#8208;1999&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">2000&#8208;2009&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">2010&#8208;2019&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">0&#44;0&#8208;0&#44;5 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;25&#44;23&#37;&#41;&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">140 &#40;41&#44;3&#37;&#41;&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">518 &#40;42&#44;42&#37;&#41;&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&#44;000001&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">0&#44;5&#8208;1&#44;0 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;21&#44;5&#37;&#41;&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 &#40;21&#44;24&#37;&#41;&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">128 &#40;10&#44;48&#37;&#41;&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">1&#44;0&#8208;1&#44;5 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;11&#44;21&#37;&#41;&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 &#40;9&#44;73&#37;&#41;&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">64 &#40;5&#44;24&#37;&#41;&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">1&#44;5&#8208;2&#44;0 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;6&#44;54&#37;&#41;&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">15 &#40;4&#44;42&#37;&#41;&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">35 &#40;2&#44;87&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-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">2&#44;0 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">38 &#40;35&#44;51&#37;&#41;&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">79 &#40;23&#44;3&#37;&#41;&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">476 &#40;38&#44;98&#37;&#41;&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 ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">107 &#40;100&#37;&#41;&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">339 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1221 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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          "pt" => "<p id="spar0165" class="elsevierStyleSimplePara elsevierViewall">Distribui&#231;&#227;o de frequ&#234;ncia absoluta e relativa percentual do melanoma cut&#226;neo&#44; de acordo com espessura de Breslow&#44; Blumenau &#40;SC&#41;&#44; de 1995 a 1999&#44; de 2000 a 2009 e de 2010 a 2019</p>"
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      "titulo" => "Refer&#234;ncias"
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        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:25 [
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                0 => array:1 [
                  "referenciaCompleta" => "seer&#46;cancer &#91;Internet&#93;&#46; National Cancer Institute&#46; Surveillance&#44; epidemiology&#44; and end results program&#46; Cancer stat facts&#58; melanoma of the skin&#46; &#91;citado em 05 set&#46; 2019&#93;&#46; Dispon&#237;vel em&#58; https&#58;&#47;&#47;seer&#46;cancer&#46;gov&#47;statfacts&#47;html&#47;melan&#46;html&#46;"
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                      "doi" => "10.1016/j.jaad.2011.04.032"
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Journal Information
Vol. 98. Issue 5.
Pages 611-619 (1 September 2023)
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3691
Vol. 98. Issue 5.
Pages 611-619 (1 September 2023)
Artigo original
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Epidemiologia dos melanomas cutâneos em Blumenau, Santa Catarina, Brasil, de 1980 a 2019
Visits
3691
Nilton Nasser
Corresponding author
ninasser.bnu@terra.com.br

Autor para correspondência.
, Joana Laurindo da Silva, Grazielle Corrêa
Departamento de Dermatologia, Universidade Regional de Blumenau, Blumenau, SC, Brasil
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Abstract
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Figures (2)
Tables (8)
Tabela 1. Taxas de incidência de melanoma cutâneo primário, segundo o ano e sexo, em Blumenau (SC), 1980 a 2019
Tabela 2. Média das taxas de incidência de melanoma cutâneo, segundo o ano e sexo, em Blumenau (SC), 1980 a 2019
Tabela 3. Distribuição numérica e percentual do melanoma cutâneo por faixa etária, e sexo ‐ Blumenau‐SC, de 1980 a 2019
Tabela 4. Taxas de incidência do melanoma maligno por 100.000 habitantes, segundo a faixa etária, em Blumenau (SC), nos anos de 1980, 2008 e 2018
Tabela 5. Percentual de incidência do tipo histológico do melanoma cutâneo, segundo sexo, em Blumenau (SC), de 1980‐2019
Tabela 6. Distribuição numérica e percentual do melanoma, segundo localização primária e sexo, em Blumenau‐SC, de 1980 a 2019
Tabela 7. Distribuição percentual do melanoma maligno, por décadas, de acordo com o nível de Clark, Blumenau (SC)
Tabela 8. Distribuição de frequência absoluta e relativa percentual do melanoma cutâneo, de acordo com espessura de Breslow, Blumenau (SC), de 1995 a 1999, de 2000 a 2009 e de 2010 a 2019
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Resumo
Fundamentos

A incidência e a mortalidade do melanoma aumentaram nos últimos anos na população caucasiana. Este estudo de 40 anos descreve a incidência do melanoma em Blumenau (SC, Brasil) e mostra o impacto da prevenção primária na redução da mortalidade.

Objetivos

Avaliar a incidência e classificar melanomas cutâneos na cidade de Blumenau no período de 1980 a 2019.

Métodos

Este estudo retrospectivo, descritivo e transversal coletou 2.336 exames histopatológicos de indivíduos moradores da cidade de Blumenau, considerando sexo, idade, localização primária, tipo histopatológico, nível de invasão e espessura tumoral. Os coeficientes de incidências anuais foram calculados utilizando o número de melanomas e a população estimada pelo Instituto Brasileiro de Geografia e Estatísticas entre os anos de 1980 e 2019.

Resultados

As taxas de incidência do melanoma atingiram 44,26 casos/100.000 habitantes/ano, e por sexo chegou a 52,87 em homens e 46,73 casos em mulheres por 100.000 habitantes. A faixa etária mais afetada foi ≥ 70 anos, com 421 casos para homens e 301 casos para mulheres por 100.000 habitantes. O melanoma extensivo superficial foi o mais frequente, com 64,5% dos casos, seguido do melanoma nodular, com 22,8%. Os diagnósticos precoces atingiram 1900%, com Breslow <0,5 mm.

Limitações do estudo

Esta pesquisa abrange apenas exames histopatológicos com diagnóstico definitivo de melanoma cutâneo; portanto, os dados são subestimados, resultando, consequentemente, em taxas menores que na realidade.

Conclusões

A incidência do melanoma cutâneo aumentou em cinco vezes entre os anos de 1980 e 2019, e o diagnóstico precoce aumentou em relação a 1980 como resultado da educação sanitária da população e prevenção primária.

Palavras‐chave:
Educação sanitária
Epidemiologia
Melanoma
Neoplasias cutâneas
Fatores de risco
Full Text
Introdução

O melanoma maligno, por sua letalidade, tem grande importância médica; sua incidência tem aumentado em vários países nos últimos 40 anos.1–5 Os fatores de risco estão principalmente ligados à população caucasiana submetida à radiação ultravioleta, com histórico familiar, presença de nevus melanocíticos e imunossupressão.2–5

Para 2020, estimaram‐se 106.110 novos casos nos Estados Unidos e 8.450 casos no Brasil, dos quais 4.200 em homens e 4.250 em mulheres.6 Os coeficientes de morbidade do melanoma atingem 51,7 casos por 100.000 habitantes na Austrália, considerada uma das taxas mais altas do mundo.4

Na região Sul do Brasil, o câncer de pele melanoma é mais incidente quando comparado com as demais regiões, para ambos os sexos.6,7 As taxas de incidência anual do melanoma por 100.000 habitantes estimadas nas capitais do Sul do Brasil em 2019 pelo Instituto Nacional de Câncer (INCA) foram de 8,3 e 7,39 em Curitiba/PR; 6,84 e 7,94 em Florianópolis/SC e 9,25 e 10,12 em Porto Alegre/RS para homens e mulheres, respectivamente – taxas comprovadamente subestimadas em relação a Blumenau/SC.6–8

No Brasil, dados sobre coeficiente de incidência do melanoma cutâneo são raros e muito subestimados em municípios, capitais, estados e no próprio país, demonstrando a necessidade de estudos epidemiológicos específicos.

A cidade de Blumenau está localizada no nordeste do estado de Santa Catarina, latitude 26°55’10” Sul, longitude 49°03’58”, a 21 metros do nível do mar.9 A população caucasiana, formada em sua maioria por descendentes de alemães e italianos, com fototipos I e II de acordo com a classificação de Fitzpatrick,8 está sujeita a intensa radiação no verão, com índice de radiação ultravioleta B (UVB) entre 11,5 e 13,0 conforme o Instituto Nacional de Pesquisas Espaciais (INPE) e muito alto de acordo com a Environonmental Protection Agency/Operational Satellites (EPA/NOOA) dos Estados Unidos – portanto, exposta aos principais fatores de risco do melanoma.10

O objetivo deste estudo retrospectivo de 40 anos (1980‐200911 mais 2010‐2019) é descrever as características epidemiológicas do melanoma cutâneo na cidade de Blumenau, apresentando dados estatísticos que poderão servir de referência para estudos epidemiológicos e prevenção da doença no Sul do Brasil. A longevidade deste trabalho possibilita mostrar o impacto das ações da educação sanitária na prevenção e no tratamento precoce do melanoma cutâneo.

Métodos

Este é um estudo retrospectivo, descritivo e transversal que coletou 2.336 casos de melanoma cutâneo primário nos três únicos laboratórios de anatomia patológica existentes na cidade, CIPAC (Laboratório de Citologia, Imunopatologia e Anatomia Patológica ‐ entre 1980 e 2019), BML (Laboratório Beatriz Moreira Leite) e Pathology Diagnóstico em Medicina.

Os dados coletados em protocolo pelos autores incluíam características dos pacientes (idade, sexo, localização do tumor) e aspectos histopatológicos do melanoma. Como critérios de inclusão e exclusão na revisão dos casos, foram considerados apenas pacientes provenientes do município de Blumenau e excluídos casos de pacientes residentes em outros municípios, para a fidelidade dos cálculos dos coeficientes de morbidade.

As taxas de incidência de melanoma cutâneo por 100.000 habitantes para a cidade de Blumenau foram calculadas com base na população anual entre 1980 e 2019 estimadas pelo Instituto Brasileiro de Geografia e Estatística (IBGE)9 e casos encontrados anualmente, para que pudessem ser comparadas com os coeficientes de outras cidades, estados e países. Os dados foram digitados e calculados no programa Excel versão 2016, somando dados de 2010 a 2019 com os publicados de 1980 a 2009 nos Anais Brasileiros de Dermatologia.10 Foram utilizados testes Qui‐Quadrado, teste de Mann‐Whitney, teste de Kruskal Wallis (teste não paramétrico), teste de Dun e correlação de Spearman. A pesquisa foi aprovada pelo Comitê de Ética em Experimentos em Seres Humanos da Universidade Regional de Blumenau, conforme Certificado de Apresentação de Apreciação Ética (CAAE) 42905821.2.0000.5370 e Parecer Consubstanciado do Comitê de Ética n° 4.580.124.

Resultados

O total de casos de melanoma cutâneo primário entre 1980 e 2019 foi de 2.336, dos quais 44% (n=1.078) ocorreram em pacientes do sexo masculino e 56% (n=1.258) em pacientes do sexo feminino.

A tabela 1 mostra as taxas anuais de incidência geral e por sexo do melanoma cutâneo primário no município de Blumenau entre 1980 e 2019.11 Ressaltamos as taxas de incidência gerais de 42,2 (2011) e 44,26 (2018) casos por 100.000 habitantes/ano de melanoma cutâneo primário e de 52,87 (2011) e 41,7 (2018)/100.000 habitantes no sexo masculino (tabela 1). As taxas de incidência no sexo feminino foram de 46,7/100.000 habitantes em 2018 e 44 em 2013 (tabela 1).

Tabela 1.

Taxas de incidência de melanoma cutâneo primário, segundo o ano e sexo, em Blumenau (SC), 1980 a 2019

Ano  Masculino  Feminino  Geral  Ano  Masculino  Feminino  Geral 
1980  5,2  3,7  4,4  2000  13,4  13,5  13,45 
1981  10,9  2001  14,5  23,5  19 
1982  11,1  8,3  9,7  2002  12  23  17,5 
1983  11,8  10,3  11  2003  13,2  17.7  15,45 
1984  6,9  5,5  6,2  2004  13,7  19,5  16,6 
1985  13,4  15  14,2  2005  13,2  20  16,6 
1986  8,7  8,4  8,5  2006  15  15,7  15,35 
1987  10,6  12,2  11,4  2007  14,8  31,5  23,15 
1988  7,3  6,9  6,6  2008  18  23,1  20,6 
1989  15,2  12,6  13,8  2009  24,1  20,3  22,2 
1990  22  17,1  18,9  2010  36,3  39,31  37,83 
1991  14,6  12  12,2  2011  52,87  31,9  42,2 
1992  14,4  10,9  10,2  2012  41,31  39,07  40,17 
1993  22,8  17,4  15,8  2013  35,34  44,09  39,8 
1994  15  11,36  9,79  2014  37,27  44,02  40,71 
1995  22  18,7  14,4  2015  35,53  43,39  39,54 
1996  22,6  17,9  16,8  2016  38  38,67  38,34 
1997  3,4  3,3  2017  41  39,94  39,88 
1998  23  17,2  13,7  2018  41,7  46,73  44,26 
1999  21,9  17,7  18,8  2019  33,13  40,62  39,95 

Fonte: Instituto Brasileiro de Geografia e Estatística (IBGE), Laboratório de Citologia, Imunopatologia e Anatomia Patológica (CIPAC), Pathology Diagnóstico em Medicina e Beatriz Moreira Leite (BML) Patologia (anos 1980 a 1990).

* Por 100.000 habitantes.

A tabela 2 apresenta a média das taxas de incidência por grupos de anos, com significância no período de 2000 a 2004, cuja incidência de melanoma cutâneo foi significantemente maior no sexo feminino (p=0,0279). Nos demais períodos, não houve significância.

Tabela 2.

Média das taxas de incidência de melanoma cutâneo, segundo o ano e sexo, em Blumenau (SC), 1980 a 2019

Período  Masculino  Feminino  Geral 
  (Média±DP)  (Média±DP)  (Média±DP)   
1980 a 1984  (8±3,24)  (7,74±3,09)  (7,87±2,99)  0,9000 
1985 a 1989  (11,04±3,26)  (11,02±3,3)  (11,03±3,09)  0,9925 
1990 a 1994  (17,76±4,25)  (13,75±3,22)  (15,76±4,13)  0,1313 
1995 a 1999  (18,58±8,5)  (14,96±6,54)  (16,77±7,4)  0,4720 
2000 a 2004  (13,36±0,91)  (19,44±4,11)  (16,4±4,26)  0,0279 
2005 a 2009  (17,02±4,32)  (22,12±5,87)  (19,57±5,55)  0,1564 
2010 a 2014  (40,62±7,22)  (39,68±4,98)  (40,15±5,87)  0,8166 
2015 a 2019  (37,87±3,62)  (41,87±3,22)  (39,87±3,86)  0,1022 
1980 a 2019  (20,53±12,32)  (21,32±12,81)  (20,93±12,49)  0,7790 

Fonte: Instituto Brasileiro de Geografia e Estatística (IBGE), Laboratório de Citologia, Imunopatologia e Anatomia Patológica (CIPAC), Pathology Diagnóstico em Medicina e Beatriz Moreira Leite (BML) Patologia (anos 1980 a 1990).

* Por100.000/habitantes.

p, Valor‐p do Teste de Mann‐Whitney (teste não paramétrico, compara duas amostras independentes).

A faixa etária de maior incidência foi acima de 55 anos, com 57% dos casos (n=1.321); abaixo de 39 anos, foram 14,9% dos casos (n=343), com 95% de confiança (tabela 3).

Tabela 3.

Distribuição numérica e percentual do melanoma cutâneo por faixa etária, e sexo ‐ Blumenau‐SC, de 1980 a 2019

Faixa etária  Masculino  95% IC  Feminino  95% IC  Total  95% IC 
0‐39 anos  178  16,6  (14,45‐18,92)  165  13,44  (11,54‐15,36)  343  14,9  (13,49‐16,41) 
40‐54 anos  277  26  (23,33‐28,59)  353  28,76  (26,24‐31,3)  630  27,45  (25,64‐29,29) 
55‐64 anos  253  23,7  (21,16‐26,26)  288  23,47  (21,1‐25,84)  541  23,5  (21,85‐25,32) 
65‐70+  359  33,7  (30,81‐36,48)  421  34,33  (31,65‐36,97)  780  34,15  (32,06‐35,94) 
TOTAL  1.067  100    1.227  100    2.294  100   

Fonte: Instituto Brasileiro de Geografia e Estatística (IBGE), Laboratório de Citologia, Imunopatologia e Anatomia Patológica (CIPAC), Pathology Diagnóstico em Medicina e Beatriz Moreira Leite (BML) Patologia (anos 1980 a 1990).

IC, intervalo de confiança (estimativas de incidência com 95% de confiança).

Na tabela 4, a fim de verificar o aumento do coeficiente de incidência em cada período e ao longo das faixas etárias, foi utilizado o teste de Mann‐Whitney e a correlação de Spearman. Ambas as técnicas pertencem à estatística não paramétrica. Justifica‐se a utilização de tal estatística considerando‐se a rejeição da hipótese nula do teste de normalidade (teste de Shapiro‐Wilk) – ou seja, segundo o teste de normalidade realizado, os dados não aderem a um modelo de distribuição normal.

Tabela 4.

Taxas de incidência do melanoma maligno por 100.000 habitantes, segundo a faixa etária, em Blumenau (SC), nos anos de 1980, 2008 e 2018

Faixa etária (em anos)  Coeficiência de incidência bruta 1980Coeficiência de incidência bruta 2000Coeficiência de incidência bruta 2018
  Masculino  Feminino  Total  Masculino  Feminino  Total  Masculino  Feminino  Total 
0‐19 
20‐24  8,0  4,0 
25‐29  8,6  8,3  8,5  11,4  5,9  8,7 
30‐34  8,3  8,2  8,3  6,3  12,6  9,5 
35‐39  47,2  22,3  34,4  17,3  8,4  12,8  21,6  6,8  13,9 
40‐44  10,7  5,2  28,8  40,8  34,9 
45‐49  12  6,3  31,2  36,6  34 
50‐54  40  32,2  16,5  25,6  50,1  71,9  61,6 
55‐59  24,2  53,7  70  63  63,8  66,9  65,5 
60‐64  56,2  29,7  71  58  64  74,9  185,9  135,6 
65‐69  150  73  105  253  128,7  182,5 
70+  66,7  44,8  53,6  125,7  57,7  83,5  421,6  301,1  344,2 
  198020002018p     
Masculino                   
(Média±DP)  (12,83±23,94)(33,17±30,52)(80,23±127,62)     
(Mediana±DQ)  (0±5)a(20,05±14,7)ab(30±28,23)b0,0218     
Feminino                   
(Média±DP)  (10,28±19,99)(36,3±38,8)(71,43±92,17)     
(Mediana±DQ)  (0±2,79)b(22,5±11,06)a(38,7±39,76)a0,0122     
Total                   
(Média±DP)  (11,83±18,7)(37,66±35,43)(74,2±102,21)     
(Mediana±DQ)  (0±12,79)a(22,45±19,29)ab(34,45±36,86)b0,0289     

Fonte: Instituto Brasileiro de Geografia e Estatística (IBGE), Laboratório de Citologia, Imunopatologia e Anatomia Patológica (CIPAC), Pathology Diagnóstico em Medicina e Beatriz Moreira Leite (BML) Patologia (anos 1980 a 1990).

I – DP, desvio padrão; DQ, desvio quartílico.

II – p, Valor‐p do Teste de Kruskal Wallis (Teste não paramétrico). Letras diferentes representam diferenças significantes entre anos (Teste de Dun). Se p <0,05, então diferenças significantes.

III – R, correlação de Spearman. Homens: R (1980 e 2008)=22,9% e R (2008 e 2018)=97%. Mulheres: R (1980 e 2008)=48,6% e R (2008 e 2018)=80,9%. Total: R (1980 e 2008)=57% e R (2008 e 2018)=96,7%.

Como resultado dessa parte inferencial, tem‐se que tanto nos homens quanto nas mulheres o coeficiente de incidência teve aumento significativo de 1980 para 2018. Por outro lado, apresentou correlação muito forte nos anos de 2008 e 2018, o que indica maior concentração do número de casos nas faixas etárias mais avançadas.

Em 2018, a taxa de incidência no sexo masculino atingiu 253 casos/100.000 habitantes/ano na faixa etária de 65‐69 anos e 421 casos por 100.000 habitantes na faixa etária ≥ 70 anos. No sexo feminino, no mesmo ano, encontramos 128 casos/100.000 habitantes/ano na faixa etária de 65‐69 anos, e 301 casos na faixa ≥ 70 anos (tabela 4).

A tabela 5 apresenta os tipos histológicos mais frequentes: melanoma disseminativo superficial, com 64,5% (n=996) entre 1980 e 2019, seguido pelo melanoma nodular com 22,8% (n=353). Os lentigos malignos melanoma atingiram 9,4% (n=143), e o melanoma acrolentiginoso, 3,3% (n=51).

A distribuição do tipo histológico segundo o sexo mostrou predominância de 68,5% (n=569) do tipo disseminativo superficial nas mulheres (p=0,00050) e 60% nos homens (tabela 5).

Tabela 5.

Percentual de incidência do tipo histológico do melanoma cutâneo, segundo sexo, em Blumenau (SC), de 1980‐2019

Tipo histológico  Masculino  Feminino  Total 
Lentigo maligno  66  9,3  77  9,2  143  9,27  0,99800 
Acrolentiginoso  22  29  3,5  51  3,31  0,66130 
Disseminativo superficial  427  60  569  68,5  996  64,55  0,00050 
Nodular  197  27,7  156  18,8  353  22,88  0,00003 
TOTAL  712  100  831  100  1543  100   

Fonte: Laboratório de Citologia, Imunopatologia e Anatomia Patológica (CIPAC), Pathology Diagnóstico em Medicina e Beatriz Moreira Leite (BML) Patologia (anos 1980 a 1990).

p, Valor‐p do Teste de 2 proporções independentes.

A tabela 6 mostra a distribuição numérica e percentual do melanoma cutâneo segundo localização primária e sexo, com predominância de 49,5% (n=366) de localização primária no tronco dos homens (p=0,0001) e de 35,3 (n=267) no das mulheres.

Tabela 6.

Distribuição numérica e percentual do melanoma, segundo localização primária e sexo, em Blumenau‐SC, de 1980 a 2019

Localização primária  Masculino  Feminino  Total 
Cabeça  84  11,37  43  5,68  127  8,49  0,00008 
Face  96  12,99  88  11,62  184  12,30  0,42134 
Tronco  366  49,53  267  35,27  633  42,31  0,00001 
Membros superiores  98  13,26  191  25,23  289  19,32  0,00001 
Membros inferiores  95  12,86  168  22,19  263  17,58  0,00001 
Total  739  100,00  757  100,00  1496  100,00   

Fonte: Laboratório de Citologia, Imunopatologia e Anatomia Patológica (CIPAC), Pathology Diagnóstico em Medicina e Beatriz Moreira Leite (BML) Patologia (anos 1980 a 1990).

A tabela 7 apresenta a distribuição percentual dos casos de melanoma de acordo com o nível de Clark entre 1980 e 1999, 2000 a 2009 e 2010 a 2019, destacando o aumento percentual dos diagnósticos precoces (níveis I e II de Clark) de 24,95% entre 1980‐1990 para 49,8% de 2010 a 2019. Significa aumento de 199,6% nos diagnósticos precoces no período de 2010 a 2019 em comparação ao período de 1980 a 1990.10 Entre os anos de 2010 a 2019, houve aumento significante do número de casos de melanoma nos níveis de Clark I e II e no nível V, de acordo com o teste Qui‐quadrado. Pode‐se observar melhor esse aumento na figura 1.

Tabela 7.

Distribuição percentual do melanoma maligno, por décadas, de acordo com o nível de Clark, Blumenau (SC)

Nivel de Clark  1980‐1990  2000‐2009  2010‐2019 
179 (29%)  73 (18%)  338 (27,5%)  0,00001 
II  120 (20%)  114 (27,8%)  274 (22,3%)   
III  63 (10%)  76 (18,70%)  130 (10,57%)   
IV  141 (23%)  54 (14,20%)  152 (12,36%)   
108 (18%)  87 (21,30%)  335 (27,25%)   

Fonte: Laboratório de Citologia, Imunopatologia e Anatomia Patológica (CIPAC), Pathology Diagnóstico em Medicina e Beatriz Moreira Leite (BML) Patologia (anos 1980‐1990).

p, valor‐p do teste Qui‐quadrado de independência. Se p <0,05, então associação significante.

Figura 1.

Distribuição numérica do melanoma cutâneo primário, segundo nível de Clark por décadas 1980 a 1990, 2000 a 2009 e 2010 a 2019; Blumenau (SC)

(0.14MB).

A tabela 8 mostra a distribuição percentual dos melanomas de acordo com o índice de espessura de Breslow entre 1995 e 1999,10 2000 e 200910 e de 2010 a 2019. Os melanomas diagnosticados com espessura <1mm atingiram 46,7% entre 1995 e 199910 e aumentaram para 63% entre 2000 e 2009,10 chegando a 58% entre 2010 a 2019 (p=0,000001).

Tabela 8.

Distribuição de frequência absoluta e relativa percentual do melanoma cutâneo, de acordo com espessura de Breslow, Blumenau (SC), de 1995 a 1999, de 2000 a 2009 e de 2010 a 2019

Espessura de Breslow  1995‐1999  2000‐2009  2010‐2019 
0,0‐0,5 mm  27 (25,23%)  140 (41,3%)  518 (42,42%)  0,000001 
0,5‐1,0 mm  23 (21,5%)  72 (21,24%)  128 (10,48%)   
1,0‐1,5 mm  12 (11,21%)  33 (9,73%)  64 (5,24%)   
1,5‐2,0 mm  7 (6,54%)  15 (4,42%)  35 (2,87%)   
2,0 mm  38 (35,51%)  79 (23,3%)  476 (38,98%)   
Total  107 (100%)  339 (100%)  1221 (100%)   

Fonte: Laboratório de Citologia, e Anatomia Patológica (CIPAC) e Pathology Diagnóstico em Medicina.

p, valor‐p do teste Qui‐Quadrado de independência. Se p <0,05, então associação significante.

No último período (2010‐2019) houve aumento significante do percentual do melanoma cutâneo nas categorias de espessura de 0,0 a 0,5mm e >2,0mm.

Houve aumento de 134% da frequência na espessura de Breslow entre 0‐1mm (diagnóstico precoce) no período de 2000 e 200810 em relação ao período de 1995 a 1999 e de 1918% de melanoma (in situ) <0,5mm em 2010 a 2019 (518 casos) em relação a 1995‐1999 (27 casos; p=0,000001). A figura 2 ilustra esse aumento significante do número percentual de casos, evidenciado pelo teste Qui‐Quadrado.

Figura 2.

Distribuição número de casos melanoma primário de 1995 a 1999, 2000 a 2009 e 2010 a 2019, Blumenau (SC)

(0.13MB).
Discussão

Esta pesquisa abrange apenas exames histopatológicos com diagnósticos definitivos de melanoma cutâneo primário; portanto, os dados são subestimados, resultando consequentemente em taxas menores que a realidade, porém altas em relação às taxas de incidência encontradas no Brasil e no mundo.

O estudo mostra que a morbidade do melanoma cutâneo em Blumenau aumentou de 4,4 (1980)11 para 44,26 casos por 100.000 habitantes (tabela 1), com crescimento brutal da incidência, cerca de 1000% na morbidade por 100.000 habitantes em relação a 1980.11

As taxas ajustadas para a população mundiais encontradas foram de 25,86 casos de melanoma por 100.000 habitantes/ano baseadas em casos diagnosticados entre 1975‐2017 originadas de 17 áreas geográficas do SEER.12

Como não foi realizada a incidência por idade (SEER)12 e como nas últimas décadas houve ganho na expectativa de vida, parte do aumento dos diagnósticos pode ser explicado em função da extensão da sobrevida do grupo de idosos de maior risco.

Os coeficientes de morbidade de melanoma cutâneo encontrados em Blumenau estão próximos dos esperados para os descendentes de europeus (alemães e italianos), caucasianos de pele clara vivendo em região geográfica com alto índice de radiação UV.1,3,12

Sexo

Na população mundial, a incidência do melanoma cutâneo no sexo feminino subiu de 8,2012 em 1980 para 26,4 casos por 100.000 habitantes em 2017; no sexo masculino, aumentou de 9,44 em 198012 para 33,31 por 100.000 habitantes em 2017 – taxas ajustadas para o padrão mundial.12

Na Inglaterra, a taxa de incidência ajustada para padrão mundial atingiu nas mulheres 24,5 casos por 100.000 habitantes em 2017 e nos homens 28,8 casos no mesmo ano.13

Na Alemanha, com população caucasiana como a encontrada em Blumenau, os coeficientes de morbidade encontrados em Northrhine‐Westphalia foram de 13,6 casos por 100.000 habitantes nos homens e de 18,5 nas mulheres.14

No Brasil existe maior mortalidade nos homens, provavelmente em decorrência do diagnóstico tardio.15 Em Blumenau, entre 1980 e 2019, foram estudados 2.336 casos de melanoma cutâneo primário, dos quais 1.078 do sexo masculino (46%) e 1.258 do sexo feminino (54%). A taxa de incidência mais alta no sexo feminino atingiu 46,73 casos/100.000 habitantes em 2018, e no sexo masculino foram registrados 52,87 casos/100.000 habitantes (tabela 1).

Observa‐se predominância significante da incidência no sexo feminino a partir do ano 2000 em decorrência da maior sobrevida feminina nesse período. A predominância feminina aparece clara na tabela 2, e pode ser considerada consequência de maior atenção às campanhas de esclarecimentos para diagnósticos precoces e maior cuidado com a saúde das mulheres.

Grupo etário

O melanoma cutâneo causa mais mortes do que qualquer outro tumor cutâneo, e as taxas de incidência e mortalidade têm aumentado nos últimos anos, principalmente em pacientes com idade avançada.15,16 De 1992 a 2006, as taxas de incidência de melanoma entre brancos não hispânicos aumentaram para todas as idades. As taxas de mortalidade aumentaram para pessoas mais velhas (> 65 anos), mas não para pessoas mais jovens.15,16

Nos Estados Unidos, há predominância da taxa de incidência do melanoma cutâneo no grupo etário acima de 55 anos.17 A incidência do melanoma no Reino Unido e nos Estados Unidos entre 1973 e 2002 aumentou em todos os grupos etários, tanto em homens quanto em mulheres.

Nos Estados Unidos, homens entre 55‐64 anos tiveram aumento de 12,4 para 56,1 casos/100.000 habitantes, e aqueles acima de 65 anos tiveram aumento de 18,8 para 104,4/100.000 habitantes.17

Neste estudo, houve incidência percentual de 57,65% de melanomas no grupo acima de 54 anos no período de 1980‐2019 (tabela 2) e de 14,9% na faixa etária menor de 39 anos. As taxas de incidência bruta por 100.000 habitantes e por faixa etária e sexo nos anos de 1980, 2008 e 2018 encontradas em Blumenau mostraram altos coeficientes de morbidade nos grupos etários acima de 50 anos. A taxa de incidência na faixa etária de 65‐69 anos foi de 106 casos por 100.000 habitantes no sexo masculino em 2008 e 253 casos/100.000 habitantes em 2018. No sexo feminino, na faixa etária de 65‐69 foi de 77,2 em 2008 e 128,7 casos por 100.000 habitantes em 2018. Nas pessoas ≥ 70 anos o coeficiente de morbidade por 100.000 habitantes chegou a 421 casos nos homens e 301 casos nas mulheres em 2018 (tabela 4).

A tabela 4 mostra também as medias de incidência nos anos estudados e todos os testes de confiança, de desvio padrão e de correlação para tornar mais fidedignos os dados relatados.

A alta incidência do melanoma cutâneo está fortemente relacionada à idade, com as taxas de incidência específicas por idade aumentando acentuadamente de 50 anos para o pico em pessoas com mais de 75 anos. Essa alta incidência sugere programas de prevenção mais apurados e efetivos para essa faixa etária no município e em outras regiões com população caucasiana semelhante à de Blumenau.

Localização primária

No Canadá, em 2019, um estudo de 50 anos mostrou que a localização mais frequente foi no tórax (área coberta) principalmente em homens, e a localização nos membros inferiores é mais comum nas mulheres. O mesmo ocorre nos Estados Unidos.18

Em Blumenau, a localização primária do melanoma cutâneo primário mais comum em 42,3% dos casos foi no tronco (57,8% nos homens e 42,2% nas mulheres). Nos membros inferiores, a incidência foi mais comum nas mulheres (63,9%; p=0,00001), enquanto entre os homens foi de 36,1% (tabela 6). Podemos relacionar esses dados com o uso de saias pelas mulheres e calças compridas pelos homens.

Histopatologia

Num estudo de 771 casos revistos de melanoma no Texas e na Califórnia, o melanoma lentigo maligno foi o mais frequente, com 56% dos casos e com 29% de melanoma disseminativo superficial.19,20

Em Blumenau, entre 1980 e 2019, o melanoma disseminativo superficial foi o mais frequente (64,5%), com 68,5% no sexo feminino (p=0,00050) e 60% no sexo masculino. O segundo tipo histológico mais comum foi melanoma nodular (22,8%), seguido do melanoma lentigo maligno (9,4%) e o acrolentiginoso (3,3%) – tabela 4.

O melanoma nodular aparece em todos os estudos com maior mortalidade em decorrência do nível de invasão mais avançados.19–21 O estadiamento do diagnóstico não é possível realizar porque o estudo baseou‐se apenas em laudos histopatológicos.

Nível de invasão

A sobrevida do paciente depende da espessura e do nível de invasão do melanoma cutâneo primário e sua redução encontrada nos exames histopatológicos equivalem ao diagnóstico precoce e à melhora da sobrevida.21,22

Pacientes com melanoma cutâneo primário com espessura de Breslow <1mm são considerados de baixo risco e com excelente prognóstico de sobrevida, podendo levar a mortalidade a zero.21,22

Em Blumenau, no período de 1980 a 1990,11 25% dos diagnosticados com melanoma cutâneo primário eram dos níveis I e II de Clark, e entre 2010‐2019 esse percentual passou a ser de 49,8% dos casos (p=0,00001), com aumento de 199%, com possível melhora da sobrevida (tabela 7).10,21,22 A figura 1 mostra claramente o número de diagnósticos precoces representados pelos níveis I e II de Clark.

De 2000 a 2009,11 conforme espessura de Breslow, a porcentagem de diagnóstico precoce foi de 62,5% para os melanomas <1mm, e de 2010 a 2019 foi de 52,85% (tabela 8). Valor semelhante foi relatado nos EUA, onde 66% de todos os melanomas diagnosticados entre 1988 e 1999 apresentaram espessura de Breslow <1mm.22‐24

Este estudo mostra, então, que houve aumento dos diagnósticos precoces comparando os dados dos índices de Breslow no período de 2000 a 200910 e 2010 a 2019 com os dados do período de 1995 a 199911 (tabela 8).

Analisando as tabelas 7 e 8, notamos que os melanomas finos (< 1mm Breslow e níveis I e II de Clark) encontrados podem indicar maior sobrevida dos pacientes com melanoma maligno, a qual é inversamente proporcional à espessura do tumor.21,22 Considerando os melanomas “finos”, verifica‐se aumento da possível melhora da sobrevida de 199% de acordo com o nível de Clark (tabela 7) em 2019 em relação a 1980,11 e de 113% de sobrevida segundo espessura de Breslow na década de 2010‐2019 em relação a 1995‐199910 (tabela 8).

Os diagnósticos de melanomas in situ (0‐0,5 mm) aumentaram cerca de 1900% no período de 2010‐2019 (518 casos) em relação a 1995‐1999 (27 casos); p=0,000001. Esses dados são evidenciados na figura 2.

O aumento dos melanomas invasivos (> 2 mm) pode ser decorrente do incremento da sobrevida populacional no município.

A taxa de letalidade representada pelos melanomas “espessos” pode ter diminuído em 65% comparando as porcentagens entre 1980‐199011 com a década de 2010‐2019.

A diminuição da espessura do melanoma cutâneo nos diagnósticos histopatológicos pode ser creditada a campanhas de educação da população para a prevenção e treinamento dos profissionais de saúde para diagnóstico e tratamento precoces e o uso da dermatoscopia pelos dermatologistas. Essa evidência é demonstrada e permitida neste estudo de 40 anos, que controlou e comparou os níveis de invasão e os coeficientes de morbidade.21‐25

Conclusões

Os resultados encontrados neste estudo podem servir como referência para a maioria dos municípios do Sul do Brasil, onde há intensa radiação solar atingindo a população de pele clara, fototipos I e II, descendentes de europeus.

O aumento do diagnóstico precoce pode ser creditado às campanhas de educação e prevenção primária relatada em outros países22‐25 e realizado no Brasil pela Sociedade Brasileira de Dermatologia.

Este estudo epidemiológico de 40 anos conclui com as seguintes observações:

De 1980 a 2019, a taxa bruta do melanoma aumentou de 4,4 casos11 para 44,26/100.000 habitantes, com pico de 46,73 nas mulheres e de 52,87 nos homens e predominância de incidência do melanoma no sexo feminino com 56% dos casos (n=1.258).

Houve maior incidência do melanoma no grupo etário> 50 anos (64,9%), com pico ≥ 70 anos com 421,6 casos por 100.000 habitantes homens e 301 casos nas mulheres (2018). Predominaram os tipos histológicos disseminativo superficial, com 64,5% (n=996), seguido do melanoma nodular, com 22,8% (n=353).

Houve aumento do diagnóstico precoce no período de 2000‐2009,10 representado por 63% dos diagnósticos com espessura de Breslow <1mm, e 53% no período de 2010‐2019.

Verificou‐se também possível aumento da sobrevida21‐25 de 199% de acordo com nível de Clark em 2010‐2019 em relação a 1980‐199011 e de 113% de sobrevida segundo espessura de Breslow na década de 2010‐2019 em relação a 1995‐1999.10

A taxa de letalidade representada pelos melanomas espessos diminuiu de 75% dos casos entre 1980‐199010 para 49% na década de 2010‐2019.19,20

Diante do aumento da incidência principalmente em idosos, é essencial que se mantenham campanhas de conscientização pública dos sinais iniciais do melanoma, a regra do ABCDE, atenção para os familiares, múltiplos nevus e atendimento prioritário aos idosos.

Suporte financeiro

Nenhum.

Contribuição dos autores

Nilton Nasser: Concepção e desenho do estudo; levantamento de dados; redação do artigo e revisão crítica do conteúdo; elaboração das tabelas, nos anos de 1980 a 2019; aprovação final do manuscrito.

Joana Laurindo da Silva: Coleta de dados, aspectos legais do estudo, como aprovação do Comitê de Ética, levantamento bibliográfico; ajuda na elaboração das tabelas; aprovação final do manuscrito.

Grazielle Corrêa: Coleta de dados, levantamento de dados; ajuda na elaboração das tabelas; aprovação final do manuscrito.

Conflito de interesses

Nenhum.

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Como citar este artigo: Nasser N, Silva JL, Corrêa G. Epidemiology of cutaneous melanoma in Blumenau, Santa Catarina state, Brazil from 1980 to 2019. An Bras Dermatol. 2023;98:611–9.

Trabalho realizado na Universidade Regional de Blumenau, Blumenau, SC, Brasil.

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