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definido como o&#40;s&#41; primeiro&#40;s&#41; linfonodo&#40;s&#41; para o&#40;s&#41; qual&#40;is&#41; as c&#233;lulas de melanoma t&#234;m maior probabilidade de se disseminar&#44; a partir do tumor prim&#225;rio&#46; A bi&#243;psia do linfonodo sentinela &#40;BLNS&#41; &#233; um procedimento cir&#250;rgico no qual o LNS &#233; examinado&#44; possibilitando a previs&#227;o da situa&#231;&#227;o de met&#225;stases linfonodais do paciente&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;4</span></a> Essa t&#233;cnica &#233; precedida por uma linfocintilografia pr&#233;&#8208;operat&#243;ria para identificar a&#40;s&#41; bacia&#40;s&#41; linf&#225;tica&#40;s&#41; de drenagem&#44; que &#233; particularmente importante para regi&#245;es com drenagem altamente vari&#225;vel&#44; como tronco&#44; cabe&#231;a e pesco&#231;o&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Em vez de identificar candidatos para dissec&#231;&#227;o completa de linfonodos&#44; atualmente a BLNS desempenha um papel importante no estadiamento adequado dos pacientes e na sele&#231;&#227;o de candidatos &#224; terapia adjuvante&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A drenagem de bacias linf&#225;ticas &#40;DBL&#41; m&#250;ltiplas ocorre quando o tumor prim&#225;rio drena para m&#250;ltiplas bacias linfonodais&#44; e isso ocorre mais frequentemente em pacientes com melanoma na regi&#227;o do tronco &#40;17 a 46&#37;&#41; do que em outros locais&#44; como membros ou cabe&#231;a e pesco&#231;o&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8&#44;9</span></a> Ainda est&#225; sendo avaliado se a DBL m&#250;ltipla ou &#250;nica t&#234;m valor progn&#243;stico&#46; Estudos relacionados a essa quest&#227;o relatam achados contradit&#243;rios e pouco se sabe no caso de pacientes com BLNS negativa&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10&#8211;13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">O objetivo do presente estudo foi investigar se o padr&#227;o de DBL influencia o risco de doen&#231;a linfonodal em pacientes com melanoma na regi&#227;o do tronco e BLNS negativa&#46; O objetivo secund&#225;rio foi avaliar a taxa de resultados falsos negativos de BLNS em melanomas na regi&#227;o do tronco&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">A pesquisa foi conduzida de acordo com o Comit&#234; de &#201;tica local&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pacientes</span><p id="par0035" class="elsevierStylePara elsevierViewall">Foi realizado um estudo observacional retrospectivo&#44; incluindo todos os pacientes com melanoma cut&#226;neo de tronco com BLNS negativa&#44; diagnosticados entre outubro de 2004 e setembro de 2017 no Centro Hospitalar e Universit&#225;rio de Coimbra&#44; Coimbra&#44; Portugal&#46; Os prontu&#225;rios m&#233;dicos foram analisados desde a primeira consulta dermatol&#243;gica at&#233; a &#250;ltima avalia&#231;&#227;o ou &#243;bito&#46; Foram inclu&#237;dos no estudo pacientes com pelo menos 12 meses de seguimento&#44; ou menos&#44; em caso de progress&#227;o precoce para doen&#231;a linfonodal ou metast&#225;tica&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Dois grupos foram considerados para compara&#231;&#227;o&#58; pacientes com DBL m&#250;ltipla e DBL &#250;nica&#46; Os pacientes foram considerados como apresentando DBL m&#250;ltipla quando a BLNS foi realizada em mais de uma bacia linf&#225;tica regional&#44; independentemente do n&#250;mero total de linfonodos excisados&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Os <span class="elsevierStyleItalic">endpoints</span> inclu&#237;ram a primeira doen&#231;a linfonodal ou metast&#225;tica ap&#243;s BLNS negativa em um paciente n&#227;o submetido a nenhum outro tratamento m&#233;dico ou cir&#250;rgico at&#233; o momento&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Caracter&#237;sticas cl&#237;nicas dos pacientes &#40;idade&#44; sexo e localiza&#231;&#227;o do tumor no tronco&#41;&#44; caracter&#237;sticas histol&#243;gicas do melanoma &#40;espessura de Breslow&#44; ulcera&#231;&#227;o e subtipo histol&#243;gico&#41;&#44; padr&#227;o de drenagem linf&#225;tica &#40;n&#250;mero e localiza&#231;&#227;o de bacias linfonodais exploradas e linfonodos sentinela excisados&#41;&#44; sobrevida livre de recorr&#234;ncia linfonodal &#40;SLR linfonodal&#41;&#44; sobrevida livre de recorr&#234;ncia metast&#225;tica &#40;SLR metast&#225;tica&#41; e sobrevida livre de recorr&#234;ncia geral &#40;SLR geral&#41; foram revisados&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Uma vez que o estudo foi realizado em um per&#237;odo de 14 anos&#44; houve diferen&#231;as na abordagem da doen&#231;a metast&#225;tica regional e &#224; dist&#226;ncia &#40;ou seja&#44; diferentes indica&#231;&#245;es para dissec&#231;&#227;o completa dos linfonodos ou cirurgia para doen&#231;a metast&#225;tica&#59; indica&#231;&#245;es para terapia sist&#234;mica de doen&#231;a metast&#225;tica com quimioterapia&#44; terapia direcionada ou terapia com inibidor de <span class="elsevierStyleItalic">checkpoint</span> imunol&#243;gico&#59; e&#44; mais recentemente&#44; terapia adjuvante&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Entretanto&#44; para o prop&#243;sito do presente estudo&#44; essas mudan&#231;as nas diretrizes n&#227;o poderiam impactar os resultados&#44; uma vez que n&#227;o influenciaram o padr&#227;o de drenagem e apenas as SLR foram consideradas &#40;ou seja&#44; antes do efeito de qualquer poss&#237;vel dissec&#231;&#227;o linfonodal completa&#44; ou terapia sist&#234;mica para doen&#231;a metast&#225;tica ou em configura&#231;&#227;o adjuvante&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Excis&#227;o prim&#225;ria&#44; linfocintilografia pr&#233;&#8208;operat&#243;ria e t&#233;cnica de LNS</span><p id="par0065" class="elsevierStylePara elsevierViewall">O diagn&#243;stico de melanoma foi baseado em bi&#243;psia excisional ou bi&#243;psia incisional&#44; seguida de excis&#227;o radical e an&#225;lise histopatol&#243;gica&#46; A bi&#243;psia excisional foi realizada com margens estreitas&#46; A excis&#227;o local ampla foi realizada com margem de 1 ou 2<span class="elsevierStyleHsp" style=""></span>cm dependendo da espessura de Breslow&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Os pacientes foram selecionados para BLNS de acordo com as diretrizes recomendadas na &#233;poca&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Um protocolo de dois dias utilizando Tc&#8208;nanocoloides &#40;<span class="elsevierStyleSup">99m</span>Tc&#41; de albumina s&#233;rica humana foi utilizado para realizar uma cintilografia de LNS&#46; No dia 1&#44; as inje&#231;&#245;es foram feitas no local do melanoma prim&#225;rio&#46; Imediatamente ap&#243;s a inje&#231;&#227;o&#44; foi iniciado um estudo de imagem din&#226;mico com o campo de vis&#227;o centrado na les&#227;o&#46; Foram obtidas imagens est&#225;ticas 20 minutos e 2 horas ap&#243;s a inje&#231;&#227;o&#46; Duas horas e meia ap&#243;s a inje&#231;&#227;o do tra&#231;ador&#44; foi realizado um SPECT com tomografia computadorizada de baixa dose sem contraste&#46; No dia 2&#44; foi feita uma tentativa de bi&#243;psia do LNS em todas as bacias nodais identificadas pela linfocintilografia pr&#233;&#8208;operat&#243;ria&#46; Para esse prop&#243;sito&#44; uma gama&#8208;sonda port&#225;til foi utilizada no intraoperat&#243;rio para detectar a emiss&#227;o de radia&#231;&#227;o do LNS&#44; possibilitando assim sua identifica&#231;&#227;o e excis&#227;o&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">As bacias linfonodais inclu&#237;ram regi&#227;o axilar direita e esquerda&#44; cervical&#44; virilha&#44; escapular&#44; supraclavicular&#44; intercostal ou submandibular&#46; Os n&#243;dulos em tr&#226;nsito ou sat&#233;lites n&#227;o foram considerados como uma bacia separada&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Durante o per&#237;odo do estudo&#44; o protocolo da linfocintilografia manteve&#8208;se inalterado e foi realizada pela mesma equipe de medicina nuclear&#46; O procedimento de BLNS tamb&#233;m foi realizado pela mesma equipe de cirurgia dermatol&#243;gica do hospital&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">M&#233;todos estat&#237;sticos</span><p id="par0090" class="elsevierStylePara elsevierViewall">Utilizamos o software IBM SPSS&#174;&#44; vers&#227;o 25&#46;0 &#40;Armonk&#44; NY&#58; IBM Corp&#46;&#41;&#46; Apenas os valores de p dos testes n&#227;o param&#233;tricos foram relatados&#44; uma vez que a maioria das vari&#225;veis cont&#237;nuas apresentou uma distribui&#231;&#227;o n&#227;o normal&#46; O teste do qui&#8208;quadrado foi utilizado para comparar vari&#225;veis categ&#243;ricas entre os grupos de DBL &#250;nica e m&#250;ltipla&#46; O m&#233;todo de Kaplan&#8208;Meier e o teste de log&#8208;rank foram utilizados para comparar as estimativas de sobrevida entre os grupos&#46; A regress&#227;o log&#237;stica foi usada para testar a signific&#226;ncia das vari&#225;veis preditoras&#46; A signific&#226;ncia estat&#237;stica foi estabelecida com valor de p &#8804; 0&#44;05&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Resultados</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Caracter&#237;sticas clinicopatol&#243;gicas</span><p id="par0095" class="elsevierStylePara elsevierViewall">No per&#237;odo do estudo&#44; 206 pacientes tiveram diagn&#243;stico de melanoma na regi&#227;o do tronco e foram selecionados para realiza&#231;&#227;o de BLNS em nossa institui&#231;&#227;o&#46; Desses&#44; 147 tiveram BLNS negativa e foram considerados eleg&#237;veis para o estudo&#46; Os pacientes que n&#227;o apresentavam informa&#231;&#245;es cl&#237;nicas ou patol&#243;gicas ou que n&#227;o cumpriram o tempo de seguimento exigido foram exclu&#237;dos&#44; e um total de 135 pacientes foi inclu&#237;do no estudo&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">As caracter&#237;sticas cl&#237;nicas dos pacientes e as caracter&#237;sticas patol&#243;gicas do melanoma prim&#225;rio&#44; de acordo com o padr&#227;o de drenagem linfonodal&#44; est&#227;o resumidas na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Setenta e oito pacientes &#40;57&#44;8&#37;&#41; eram do sexo masculino&#44; com mediana de idade de 69 anos &#40;33&#8208;95&#41;&#46; O melanoma estava localizado no tronco superior em 101 pacientes &#40;74&#44;8&#37;&#41;&#44; no tronco inferior em 34 &#40;25&#44;2&#37;&#41;&#44; no t&#243;rax em 32 &#40;23&#44;7&#37;&#41; e nas costas em 103 pacientes &#40;76&#44;3&#37;&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Os subtipos histol&#243;gicos de melanoma identificados foram extensivo superficial &#40;60&#41;&#44; nodular &#40;39&#41;&#44; nevoide &#40;1&#41;&#44; spitzoide &#40;1&#41;&#44; desmopl&#225;sico &#40;1&#41; ou outro &#40;7&#41;&#46; Em 26 casos faltou a classifica&#231;&#227;o do subtipo histol&#243;gico&#44; apesar de haver informa&#231;&#245;es sobre todas as outras vari&#225;veis estudadas&#46; A m&#233;dia da espessura de Breslow foi de 1&#44;7<span class="elsevierStyleHsp" style=""></span>mm&#44; e ulcera&#231;&#227;o estava presente em 47 &#40;34&#44;8&#37;&#41; pacientes&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Durante o per&#237;odo de seguimento&#44; tr&#234;s pacientes &#40;2&#37;&#41; tiveram apenas recidiva linfonodal&#44; 24 &#40;17&#44;8&#37;&#41; desenvolveram recidiva exclusivamente metast&#225;tica e nove &#40;6&#44;7&#37;&#41; tiveram recidiva linfonodal e metast&#225;tica&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A DBL m&#250;ltipla foi identificada em 61 &#40;45&#44;2&#37;&#41; pacientes&#44; e na maioria deles &#40;88&#44;5&#37;&#41; apenas duas bacias foram exploradas&#46; Em 35 &#40;57&#44;3&#37;&#41; pacientes com DBL m&#250;ltipla houve identifica&#231;&#227;o sim&#233;trica bilateral de LNS&#58; ambas as axilas em 30 &#40;46&#44;6&#37;&#41; pacientes e ambas as virilhas em cinco &#40;8&#44;2&#37;&#41;&#46; Em seis pacientes&#44; tr&#234;s bacias foram exploradas&#59; em um &#250;nico paciente ocorreu drenagem para quatro bacias&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Dos 74 pacientes com DBL &#250;nica&#44; o LNS estava localizado principalmente na axila &#40;63&#41;&#44; e menos frequentemente na virilha &#40;7&#41;&#44; &#225;rea cervical &#40;1&#41; ou outras bacias incomuns &#40;3&#59; escapular e supraclavicular&#41; &#8211; <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Os melanomas na regi&#227;o do tronco posterior foram mais frequentemente associados a DBL m&#250;ltipla &#40;51&#44;5&#37;&#41;&#44; enquanto melanomas na regi&#227;o do tronco anterior com DBL &#250;nica foram mais comuns &#40;75&#37;&#41;&#46; Essas diferen&#231;as foram consideradas estatisticamente significativas&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">N&#227;o encontramos nenhuma outra caracter&#237;stica cl&#237;nica ou histopatol&#243;gica significantemente associada ao padr&#227;o de drenagem &#40;DBL m&#250;ltipla e DBL &#250;nica&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Drenagem de bacia linf&#225;tica&#44; sobrevida livre de recidiva e risco de doen&#231;a</span><p id="par0140" class="elsevierStylePara elsevierViewall">O per&#237;odo m&#233;dio de seguimento foi de 5&#44;6 anos &#40;1&#8208;15 anos&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Dez dos 74 &#40;13&#44;5&#37;&#41; pacientes com DBL &#250;nica desenvolveram recorr&#234;ncia linfonodal&#44; em compara&#231;&#227;o com dois dos 61 &#40;3&#44;6&#37;&#41; pacientes com DBL m&#250;ltipla &#40;p &#61; 0&#44;04&#59; <a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a> e <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">No grupo de DBL &#250;nica&#44; cinco pacientes tiveram recorr&#234;ncia linfonodal na mesma bacia identificada na BLNS&#44; o que significa uma taxa de falso&#8208;negativo de BLNS de 6&#44;76&#37; &#40;5&#47;74&#41;&#46; Em outros cinco pacientes com DBL &#250;nica&#44; a recorr&#234;ncia linfonodal desenvolveu&#8208;se em uma bacia regional n&#227;o identificada na BLNS&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Nos dois pacientes com DBL m&#250;ltipla&#44; apenas um desenvolveu recidiva linfonodal em um territ&#243;rio n&#227;o previamente estudado pela BLNS&#44; o que significa uma taxa de falso&#8208;negativo de 1&#44;63&#37; &#40;1&#47;61&#41;&#46; A taxa geral de falso&#8208;negativo para BLNS foi de 4&#44;4&#37; &#40;6&#47;135&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Na an&#225;lise de sobrevida&#44; a SLR linfonodal foi significantemente mais longa no grupo com DBL m&#250;ltipla do que no grupo com DBL &#250;nica &#40;175&#44;6 <span class="elsevierStyleItalic">vs</span>&#46; 138&#44;7 meses&#59; p &#61; 0&#44;04&#59; <a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Na an&#225;lise univariada&#44; DBL &#250;nica &#40;HR &#61; 4&#44;34&#59; p &#61; 0&#44;05&#41; e espessura de Breslow &#40;HR &#61; 1&#44;36&#59; p &#61; 0&#44;05&#41; foram os &#250;nicos fatores significantemente associados a maior risco de recorr&#234;ncia linfonodal em pacientes com LNS negativo&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Ap&#243;s ajuste para espessura de Breslow&#44; a DBL &#250;nica permaneceu associada a maior risco de recorr&#234;ncia linfonodal &#40;HR &#61; 4&#44;54&#59; p &#61; 0&#44;05&#59; <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">Embora sem signific&#226;ncia estat&#237;stica&#44; houve tend&#234;ncia a menor risco de doen&#231;a linfonodal quando o n&#250;mero de bacias aumentou &#40;HR &#61; 0&#44;24&#59; p &#61; 0&#44;06&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">O n&#250;mero de linfonodos excisados n&#227;o se correlacionou com o risco de doen&#231;a linfonodal &#40;HR &#61; 0&#44;75&#59; p &#61; 0&#44;32&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">N&#227;o foram encontradas diferen&#231;as significativas na SLR metast&#225;tica e na SLR geral entre pacientes com DBL &#250;nica ou m&#250;ltipla &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; Na regress&#227;o log&#237;stica&#44; o padr&#227;o de drenagem linf&#225;tica n&#227;o afetou o risco de recorr&#234;ncia da doen&#231;a metast&#225;tica &#40;&#224; dist&#226;ncia&#41; ou geral &#40;linfonodal e metast&#225;tica&#59; p &#61; 0&#44;27 e p &#61; 0&#44;12&#44; respectivamente&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discuss&#227;o</span><p id="par0190" class="elsevierStylePara elsevierViewall">Diversos estudos avaliaram se a DBL m&#250;ltipla ou &#250;nica t&#234;m valor progn&#243;stico em rela&#231;&#227;o &#224; doen&#231;a linfonodal ou metast&#225;tica em pacientes com melanoma na regi&#227;o do tronco&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;10&#8211;16</span></a> Entretanto&#44; as conclus&#245;es s&#227;o divergentes&#44; o que pode estar relacionado &#224; inclus&#227;o de pacientes com BLNS positiva e negativa&#46; De fato&#44; sabe&#8208;se que a BLNS positiva &#233; um forte fator progn&#243;stico e&#44; para uma avalia&#231;&#227;o precisa&#44; esses grupos devem ser avaliados de maneira independente&#46; Apenas alguns pesquisadores analisaram o impacto do padr&#227;o de drenagem em pacientes com BLNS negativa&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8&#44;14&#44;15</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Devido aos resultados controversos&#44; avaliamos retrospectivamente uma s&#233;rie de casos de melanomas na regi&#227;o do tronco em pacientes com BLNS negativa&#46; Optamos por analisar melanomas na regi&#227;o do tronco por serem respons&#225;veis pela maioria das DBL&#8208;m&#250;ltiplas&#44; e selecionamos uma &#250;nica &#225;rea anat&#244;mica para reunir uma coorte mais homog&#234;nea de pacientes&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Na presente amostra&#44; foi observado que o risco de doen&#231;a linfonodal &#40;regional&#41; foi 4&#44;54 vezes maior no grupo com DBL &#250;nica do que no grupo DBL m&#250;ltipla&#44; enquanto nenhuma diferen&#231;a foi encontrada entre os grupos com doen&#231;a metast&#225;tica ou geral &#40;linfonodal e metast&#225;tica&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Em 2013&#44; Ribero et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> em um estudo de centro &#250;nico&#44; descobriram que&#44; em pacientes com melanoma na regi&#227;o do tronco e BLNS negativa&#44; a DBL &#250;nica estava associada a uma porcentagem maior de recorr&#234;ncia da doen&#231;a em compara&#231;&#227;o com DBL m&#250;ltipla &#40;19&#37; <span class="elsevierStyleItalic">vs</span>&#46; 7&#37;&#59; p &#61; 0&#44;03&#41;&#46; Entretanto&#44; os autores n&#227;o forneceram informa&#231;&#245;es sobre a recorr&#234;ncia da doen&#231;a linfonodal e metast&#225;tica&#44; separadamente&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Posteriormente&#44; em um estudo multic&#234;ntrico de 2016&#44; Ribero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> descobriram que&#44; em pacientes com BLNS negativa&#44; a DBL m&#250;ltipla estava associada a menor risco de recorr&#234;ncia do melanoma &#40;HR &#61; 0&#44;73&#59; p &#61; 0&#44;05&#41; e morte relacionada ao melanoma &#40;HR &#61; 0&#44;68&#59; p &#61; 0&#44;001&#41;&#44; embora n&#227;o houvesse diferen&#231;a na progress&#227;o linfonodal entre os grupos&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Ao contr&#225;rio&#44; Pinero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> mostraram que&#44; em pacientes com BLNS negativa&#44; a sobrevida livre de doen&#231;a &#40;linfonodal e metast&#225;tica&#41; era baixa em DBL m&#250;ltipla&#44; mas eles inclu&#237;ram melanomas de tronco e membros&#46; Investigar melanomas em diferentes &#225;reas anat&#244;micas&#44; que podem ter progn&#243;sticos gen&#233;ticos diferentes&#44; pode apresentar risco de vi&#233;s&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Jimenez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> relataram que pacientes com BLNS negativa em melanoma na regi&#227;o do tronco e DBL m&#250;ltipla tiveram uma SLR &#40;76 <span class="elsevierStyleItalic">vs</span>&#46; 190 meses para DBL &#250;nica&#44; p &#61; 0&#44;06&#41; e sobrevida global &#40;76 <span class="elsevierStyleItalic">vs</span>&#46; 190 meses para DBL &#250;nica&#44; p &#61; 0&#44;04&#41; menos favor&#225;veis&#46; Este estudo tem a limita&#231;&#227;o de um seguimento mediano mais curto &#40;27 meses&#41;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Com um tempo de seguimento mediano de mais de 5 anos&#44; nossos dados sugerem o conceito de que em pacientes com melanoma na regi&#227;o do tronco e BLNS negativa&#44; a DBL m&#250;ltipla est&#225; associada a um intervalo livre de recorr&#234;ncia nodal aumentado&#44; enquanto nenhuma diferen&#231;a em intervalos livres de doen&#231;a metast&#225;tica ou geral &#40;metast&#225;tica e linfonodal&#41; foi encontrada&#44; de acordo com o padr&#227;o de drenagem&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Nossa hip&#243;tese &#233; que&#44; em pacientes com DBL m&#250;ltipla&#44; uma BLNS negativa pode refletir melhor uma verdadeira aus&#234;ncia de doen&#231;a linfonodal &#8211; isto &#233;&#44; o valor preditivo negativo da BLNS pode ser maior&#44; uma vez que mais bacias foram avaliadas e a aus&#234;ncia de doen&#231;a foi documentada&#46; Em nossa amostra&#44; o desenvolvimento de doen&#231;a linfonodal em territ&#243;rio n&#227;o previamente estudado pela BLNS&#44; em metade dos casos com DBL &#250;nica&#44; pode corroborar essa hip&#243;tese&#44; evidenciando uma poss&#237;vel subestimativa de outras vias linf&#225;ticas com a linfocintilografia&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Uma possibilidade &#233; que a DBL &#250;nica possa ocorrer em decorr&#234;ncia da obstru&#231;&#227;o dos canais linf&#225;ticos pelas c&#233;lulas do melanoma&#44; impossibilitando o reconhecimento das rotas migrat&#243;rias na linfocintilografia&#44; levando &#224; BLNS negativa&#46; Embora a espessura de Breslow n&#227;o tenha sido significantemente diferente nos dois grupos&#44; a invas&#227;o linfovascular ou emboliza&#231;&#227;o n&#227;o foi avaliada&#44; n&#227;o sendo poss&#237;vel descartar esse fator como causa de tal diferen&#231;a&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Pode&#8208;se questionar a acur&#225;cia da linfocintilografia original&#44; mas encontramos uma taxa geral de falsos&#8208;negativos em torno de 4&#37;&#44; semelhante ou at&#233; menor do que os valores relatados em outras s&#233;ries &#40;4 a 10&#44;8&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8&#44;17</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">As limita&#231;&#245;es deste estudo incluem sua natureza de centro &#250;nico&#44; o pequeno tamanho da amostra e a an&#225;lise retrospectiva&#46; N&#227;o avaliamos a sobrevida global&#44; pois o estudo foi realizado em um per&#237;odo de 14 anos&#44; incluindo pacientes tratados de maneiras diferentes&#46; Com a recente introdu&#231;&#227;o de terapias direcionadas e imunoterapia&#44; houve uma melhora dram&#225;tica na sobrevida em compara&#231;&#227;o com os pacientes anteriores tratados com quimioterapia&#46; Se a sobrevida global tivesse sido comparada entre os grupos&#44; isso levaria a um vi&#233;s de tratamento&#46; Al&#233;m disso&#44; a avalia&#231;&#227;o histopatol&#243;gica da presen&#231;a de invas&#227;o linfovascular enriqueceria o presente estudo&#44; para corroborar nossa hip&#243;tese&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclus&#227;o</span><p id="par0250" class="elsevierStylePara elsevierViewall">A presen&#231;a de DBL m&#250;ltipla &#233; comum em pacientes com melanoma na regi&#227;o do tronco&#44; e em pacientes com BLNS negativa pode ser um fator de risco independente para recorr&#234;ncia da doen&#231;a linfonodal&#46; Embora o padr&#227;o de drenagem n&#227;o pare&#231;a influenciar a sobrevida livre de recorr&#234;ncia geral&#44; esse fator pode ajudar a identificar pacientes com BLNS negativa com maior risco de recorr&#234;ncia linfonodal&#44; inclusive em bacias n&#227;o estudadas anteriormente pela BLNS&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Suporte financeiro</span><p id="par0255" 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="par0260" class="elsevierStylePara elsevierViewall">Francisca Morgado&#58; Concep&#231;&#227;o e planeamento do estudo&#59; revis&#227;o cr&#237;tica da literatura&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o de dados&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">Paula Soeiro&#58; Obten&#231;&#227;o&#44; an&#225;lise&#44; e interpreta&#231;&#227;o de dados&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Ana Brinca&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e &#47; ou terap&#234;utica de casos estudados&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Andr&#233; Pinho&#58; An&#225;lise estat&#237;stica&#59; concep&#231;&#227;o e planejamento do estudo&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Ricardo Vieira&#58; Concep&#231;&#227;o e planejamento do estudo&#59; participa&#231;&#227;o intelectual na conduta proped&#234;utica e&#47;ou terap&#234;utica dos casos estudados&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflito de interesses</span><p id="par0285" 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">Existem dados conflitantes sobre o valor progn&#243;stico do padr&#227;o de drenagem da bacia linf&#225;tica em pacientes com melanoma&#44; e as evid&#234;ncias s&#227;o escassas no cen&#225;rio de bi&#243;psia de linfonodo sentinela negativa&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Investigar se o padr&#227;o de drenagem da bacia linf&#225;tica influencia no risco de doen&#231;a linfonodal em pacientes com melanoma na regi&#227;o do tronco e bi&#243;psia de linfonodo sentinela negativa&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Avaliamos retrospectivamente uma s&#233;rie de pacientes com melanomana regi&#227;o do tronco e bi&#243;psia de linfonodo sentinela negativa&#46; Revisamos as caracter&#237;sticas clinicopatol&#243;gicas&#44; o padr&#227;o de drenagem linf&#225;tica e a sobrevida livre de doen&#231;a linfonodal&#44; metast&#225;tica e recorr&#234;ncia geral&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nos 135 pacientes inclu&#237;dos no estudo&#44; a drenagem de m&#250;ltiplas bacias linf&#225;ticas foi identificada em 61 &#40;45&#44;2&#37;&#41;&#46; Dez dos 74 &#40;13&#44;5&#37;&#41; pacientes com drenagem &#250;nica desenvolveram recorr&#234;ncia linfonodal&#44; em compara&#231;&#227;o com 2 dos 61 &#40;3&#44;6&#37;&#41; pacientes com drenagem m&#250;ltipla &#40;p &#61; 0&#44;04&#41;&#46; A sobrevida livre de recorr&#234;ncia linfonodal foi significantemente maior no grupo com drenagem m&#250;ltipla do que no grupo com drenagem &#250;nica &#40;175&#44;6 <span class="elsevierStyleItalic">vs</span>&#46; 138&#44;7 meses&#59; p &#61; 0&#44;04&#41;&#46; Na an&#225;lise multivariada&#44; a drenagem &#250;nica foi associada ao maior risco de recorr&#234;ncia linfonodal &#40;HR &#61; 4&#44;54&#59; p &#61; 0&#44;05&#41;&#46; Nenhuma diferen&#231;a significante foi encontrada na sobrevida livre de doen&#231;a metast&#225;tica e recorr&#234;ncia geral entre os grupos&#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">An&#225;lise retrospectiva&#44; estudo de centro &#250;nico&#44; pequena amostra&#44; informa&#231;&#245;es histopatol&#243;gicas detalhadas nem sempre presentes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#245;es</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Em pacientes com melanoma da regi&#227;o do tronco e bi&#243;psia de linfonodo sentinela negativa&#44; a drenagem de m&#250;ltiplas bacias linf&#225;ticas pode ser um fator de risco independente para a recorr&#234;ncia da doen&#231;a linfonodal&#46; Esse fator pode ajudar a identificar pacientes com bi&#243;psia de linfonodo sentinela negativa com maior risco de recorr&#234;ncia linfonodal&#46;</p></span>"
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Spitzoide&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">1&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">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Desmopl&#225;sico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">1&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">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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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"><span class="elsevierStyleHsp" style=""></span>Outro<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Desconhecido<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Localiza&#231;&#227;o</span></td><td class="td" title="\n
                  \t\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;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tronco superior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tronco inferior&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">15&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">19&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\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Localiza&#231;&#227;o</span></td><td class="td" title="\n
                  \t\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;01<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;75&#44;0&#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">8 &#40;25&#44;0&#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">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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Posterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;48&#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">53 &#40;51&#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">103&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Qualquer recorr&#234;ncia linfonodal &#40;regional&#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">10 &#40;83&#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">2 &#40;16&#44;7&#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">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">0&#44;04<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Qualquer recorr&#234;ncia metast&#225;tica &#40;distante&#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">21 &#40;63&#44;6&#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">12 &#40;36&#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">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">0&#44;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Qualquer recorr&#234;ncia da doen&#231;a &#40;geral&#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">24 &#40;66&#44;7&#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">12 &#40;33&#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">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">0&#44;09&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t" scope="col">DBL &#250;nica &#40;n &#61; 74&#41;</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">DBL m&#250;ltipla &#40;n &#61; 61&#41;&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  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#176; de bacias</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" 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
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" 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">2&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">3&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">4&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">Axila&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Axila&#44; bilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&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">Virilha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Virilha&#44; bilateral&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">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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&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">Cervical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Axila &#43; virilha&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&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">Incomum<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&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">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">Axila &#43; cervical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Axila &#43; incomum<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&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">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">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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cervical &#43; incomum<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&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">2&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">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">&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">M&#250;ltipla incomum<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8211;&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">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  """
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          "pt" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Distribui&#231;&#227;o anat&#244;mica da drenagem de bacia linf&#225;tica &#250;nica e m&#250;ltipla</p>"
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                  \t\t\t\t\tvoid\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">Fatores de risco para doen&#231;a linfonodal&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">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Idade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#44;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;06&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">Sexo masculino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#44;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;50&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">Localiza&#231;&#227;o&#58; tronco superior&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&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">Localiza&#231;&#227;o&#58; tronco anterior&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&#44;93&nbsp;\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">0&#44;94&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">Ulcera&#231;&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;06&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">DBL &#250;nica&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">N&#250;mero de bacias&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\ttable-entry\n
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                  \t\t\t\t">0&#44;06&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">N&#250;mero de LS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;75&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;32&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">Regress&#227;o multivari&#225;vel de Cox</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                      "titulo" => "ESMO consensus conference recommendations on the management of locoregional melanoma&#58; under the auspices of the ESMO Guidelines Committee"
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                      "titulo" => "Complete lymph node dissection versus no dissection in patients with sentinel lymph node biopsy positive melanoma &#40;DeCOG&#8208;SLT&#41;&#58; a multicentre&#44; randomised&#44; phase 3 trial"
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                        "tituloSerie" => "Ann Surg Oncol&#46;"
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                        "paginaInicial" => "256"
                        "paginaFinal" => "261"
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                        "paginaInicial" => "518"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Significance of multiple lymphatic basin drainage in truncal melanoma patients undergoing sentinel lymph node biopsy"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "L&#46; Su"
                            2 => "K&#46;A&#46; Griffith"
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Artigo Original
O padrão de drenagem linfática influencia o risco de recorrência linfonodal em pacientes com melanoma na região do tronco e biópsia de linfonodo sentinela negativa?
Francisca Jácome Morgadoa,
Corresponding author
fjacomemorgado@gmail.com

Autor para correspondência.
, Paula Soeirob, Ana Brincaa, André Pinhoa, Ricardo Vieiraa,c
a Departamento de Dermatovenerologia, Hospitais da Universidade de Coimbra, Coimbra, Portugal
b Departamento de Medicina Nuclear, Hospitais da Universidade de Coimbra, Coimbra, Portugal
c Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
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          "pt" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Kaplan&#8208;Meier&#58; sobrevida de recorr&#234;ncia linfonodal &#40;SLRN&#41; foi significantemente mais favor&#225;vel em pacientes com DBL m&#250;ltipla&#46; &#40;B e C&#41; N&#227;o foram encontradas diferen&#231;as significativas na sobrevida livre de recorr&#234;ncia &#224; dist&#226;ncia &#40;SLRD&#41; e na sobreviv&#234;ncia livre de recorr&#234;ncia geral &#40;SLRG&#41;&#44; de acordo com o padr&#227;o de drenagem&#46;</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">DBL&#44; drenagem de bacia linf&#225;tica&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#42;&#42; Diferen&#231;a estatisticamente significativa nas curvas de sobrevida&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">O melanoma cut&#226;neo prim&#225;rio representa 4&#37; de todos os casos de c&#226;ncer de pele e &#233; respons&#225;vel pela maioria das mortes relacionadas ao mesmo&#46; O diagn&#243;stico precoce e o tratamento eficaz&#44; em um est&#225;gio em que a cura ainda &#233; poss&#237;vel&#44; s&#227;o os objetivos prim&#225;rios&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Para o melanoma em est&#225;gio inicial&#44; os fatores progn&#243;sticos mais importantes s&#227;o a espessura de Breslow&#44; a ulcera&#231;&#227;o e a situa&#231;&#227;o do linfonodo sentinela &#40;LNS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> O LNS &#233; definido como o&#40;s&#41; primeiro&#40;s&#41; linfonodo&#40;s&#41; para o&#40;s&#41; qual&#40;is&#41; as c&#233;lulas de melanoma t&#234;m maior probabilidade de se disseminar&#44; a partir do tumor prim&#225;rio&#46; A bi&#243;psia do linfonodo sentinela &#40;BLNS&#41; &#233; um procedimento cir&#250;rgico no qual o LNS &#233; examinado&#44; possibilitando a previs&#227;o da situa&#231;&#227;o de met&#225;stases linfonodais do paciente&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;4</span></a> Essa t&#233;cnica &#233; precedida por uma linfocintilografia pr&#233;&#8208;operat&#243;ria para identificar a&#40;s&#41; bacia&#40;s&#41; linf&#225;tica&#40;s&#41; de drenagem&#44; que &#233; particularmente importante para regi&#245;es com drenagem altamente vari&#225;vel&#44; como tronco&#44; cabe&#231;a e pesco&#231;o&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Em vez de identificar candidatos para dissec&#231;&#227;o completa de linfonodos&#44; atualmente a BLNS desempenha um papel importante no estadiamento adequado dos pacientes e na sele&#231;&#227;o de candidatos &#224; terapia adjuvante&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A drenagem de bacias linf&#225;ticas &#40;DBL&#41; m&#250;ltiplas ocorre quando o tumor prim&#225;rio drena para m&#250;ltiplas bacias linfonodais&#44; e isso ocorre mais frequentemente em pacientes com melanoma na regi&#227;o do tronco &#40;17 a 46&#37;&#41; do que em outros locais&#44; como membros ou cabe&#231;a e pesco&#231;o&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8&#44;9</span></a> Ainda est&#225; sendo avaliado se a DBL m&#250;ltipla ou &#250;nica t&#234;m valor progn&#243;stico&#46; Estudos relacionados a essa quest&#227;o relatam achados contradit&#243;rios e pouco se sabe no caso de pacientes com BLNS negativa&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10&#8211;13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">O objetivo do presente estudo foi investigar se o padr&#227;o de DBL influencia o risco de doen&#231;a linfonodal em pacientes com melanoma na regi&#227;o do tronco e BLNS negativa&#46; O objetivo secund&#225;rio foi avaliar a taxa de resultados falsos negativos de BLNS em melanomas na regi&#227;o do tronco&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">A pesquisa foi conduzida de acordo com o Comit&#234; de &#201;tica local&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pacientes</span><p id="par0035" class="elsevierStylePara elsevierViewall">Foi realizado um estudo observacional retrospectivo&#44; incluindo todos os pacientes com melanoma cut&#226;neo de tronco com BLNS negativa&#44; diagnosticados entre outubro de 2004 e setembro de 2017 no Centro Hospitalar e Universit&#225;rio de Coimbra&#44; Coimbra&#44; Portugal&#46; Os prontu&#225;rios m&#233;dicos foram analisados desde a primeira consulta dermatol&#243;gica at&#233; a &#250;ltima avalia&#231;&#227;o ou &#243;bito&#46; Foram inclu&#237;dos no estudo pacientes com pelo menos 12 meses de seguimento&#44; ou menos&#44; em caso de progress&#227;o precoce para doen&#231;a linfonodal ou metast&#225;tica&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Dois grupos foram considerados para compara&#231;&#227;o&#58; pacientes com DBL m&#250;ltipla e DBL &#250;nica&#46; Os pacientes foram considerados como apresentando DBL m&#250;ltipla quando a BLNS foi realizada em mais de uma bacia linf&#225;tica regional&#44; independentemente do n&#250;mero total de linfonodos excisados&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Os <span class="elsevierStyleItalic">endpoints</span> inclu&#237;ram a primeira doen&#231;a linfonodal ou metast&#225;tica ap&#243;s BLNS negativa em um paciente n&#227;o submetido a nenhum outro tratamento m&#233;dico ou cir&#250;rgico at&#233; o momento&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Caracter&#237;sticas cl&#237;nicas dos pacientes &#40;idade&#44; sexo e localiza&#231;&#227;o do tumor no tronco&#41;&#44; caracter&#237;sticas histol&#243;gicas do melanoma &#40;espessura de Breslow&#44; ulcera&#231;&#227;o e subtipo histol&#243;gico&#41;&#44; padr&#227;o de drenagem linf&#225;tica &#40;n&#250;mero e localiza&#231;&#227;o de bacias linfonodais exploradas e linfonodos sentinela excisados&#41;&#44; sobrevida livre de recorr&#234;ncia linfonodal &#40;SLR linfonodal&#41;&#44; sobrevida livre de recorr&#234;ncia metast&#225;tica &#40;SLR metast&#225;tica&#41; e sobrevida livre de recorr&#234;ncia geral &#40;SLR geral&#41; foram revisados&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Uma vez que o estudo foi realizado em um per&#237;odo de 14 anos&#44; houve diferen&#231;as na abordagem da doen&#231;a metast&#225;tica regional e &#224; dist&#226;ncia &#40;ou seja&#44; diferentes indica&#231;&#245;es para dissec&#231;&#227;o completa dos linfonodos ou cirurgia para doen&#231;a metast&#225;tica&#59; indica&#231;&#245;es para terapia sist&#234;mica de doen&#231;a metast&#225;tica com quimioterapia&#44; terapia direcionada ou terapia com inibidor de <span class="elsevierStyleItalic">checkpoint</span> imunol&#243;gico&#59; e&#44; mais recentemente&#44; terapia adjuvante&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Entretanto&#44; para o prop&#243;sito do presente estudo&#44; essas mudan&#231;as nas diretrizes n&#227;o poderiam impactar os resultados&#44; uma vez que n&#227;o influenciaram o padr&#227;o de drenagem e apenas as SLR foram consideradas &#40;ou seja&#44; antes do efeito de qualquer poss&#237;vel dissec&#231;&#227;o linfonodal completa&#44; ou terapia sist&#234;mica para doen&#231;a metast&#225;tica ou em configura&#231;&#227;o adjuvante&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Excis&#227;o prim&#225;ria&#44; linfocintilografia pr&#233;&#8208;operat&#243;ria e t&#233;cnica de LNS</span><p id="par0065" class="elsevierStylePara elsevierViewall">O diagn&#243;stico de melanoma foi baseado em bi&#243;psia excisional ou bi&#243;psia incisional&#44; seguida de excis&#227;o radical e an&#225;lise histopatol&#243;gica&#46; A bi&#243;psia excisional foi realizada com margens estreitas&#46; A excis&#227;o local ampla foi realizada com margem de 1 ou 2<span class="elsevierStyleHsp" style=""></span>cm dependendo da espessura de Breslow&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Os pacientes foram selecionados para BLNS de acordo com as diretrizes recomendadas na &#233;poca&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Um protocolo de dois dias utilizando Tc&#8208;nanocoloides &#40;<span class="elsevierStyleSup">99m</span>Tc&#41; de albumina s&#233;rica humana foi utilizado para realizar uma cintilografia de LNS&#46; No dia 1&#44; as inje&#231;&#245;es foram feitas no local do melanoma prim&#225;rio&#46; Imediatamente ap&#243;s a inje&#231;&#227;o&#44; foi iniciado um estudo de imagem din&#226;mico com o campo de vis&#227;o centrado na les&#227;o&#46; Foram obtidas imagens est&#225;ticas 20 minutos e 2 horas ap&#243;s a inje&#231;&#227;o&#46; Duas horas e meia ap&#243;s a inje&#231;&#227;o do tra&#231;ador&#44; foi realizado um SPECT com tomografia computadorizada de baixa dose sem contraste&#46; No dia 2&#44; foi feita uma tentativa de bi&#243;psia do LNS em todas as bacias nodais identificadas pela linfocintilografia pr&#233;&#8208;operat&#243;ria&#46; Para esse prop&#243;sito&#44; uma gama&#8208;sonda port&#225;til foi utilizada no intraoperat&#243;rio para detectar a emiss&#227;o de radia&#231;&#227;o do LNS&#44; possibilitando assim sua identifica&#231;&#227;o e excis&#227;o&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">As bacias linfonodais inclu&#237;ram regi&#227;o axilar direita e esquerda&#44; cervical&#44; virilha&#44; escapular&#44; supraclavicular&#44; intercostal ou submandibular&#46; Os n&#243;dulos em tr&#226;nsito ou sat&#233;lites n&#227;o foram considerados como uma bacia separada&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Durante o per&#237;odo do estudo&#44; o protocolo da linfocintilografia manteve&#8208;se inalterado e foi realizada pela mesma equipe de medicina nuclear&#46; O procedimento de BLNS tamb&#233;m foi realizado pela mesma equipe de cirurgia dermatol&#243;gica do hospital&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">M&#233;todos estat&#237;sticos</span><p id="par0090" class="elsevierStylePara elsevierViewall">Utilizamos o software IBM SPSS&#174;&#44; vers&#227;o 25&#46;0 &#40;Armonk&#44; NY&#58; IBM Corp&#46;&#41;&#46; Apenas os valores de p dos testes n&#227;o param&#233;tricos foram relatados&#44; uma vez que a maioria das vari&#225;veis cont&#237;nuas apresentou uma distribui&#231;&#227;o n&#227;o normal&#46; O teste do qui&#8208;quadrado foi utilizado para comparar vari&#225;veis categ&#243;ricas entre os grupos de DBL &#250;nica e m&#250;ltipla&#46; O m&#233;todo de Kaplan&#8208;Meier e o teste de log&#8208;rank foram utilizados para comparar as estimativas de sobrevida entre os grupos&#46; A regress&#227;o log&#237;stica foi usada para testar a signific&#226;ncia das vari&#225;veis preditoras&#46; A signific&#226;ncia estat&#237;stica foi estabelecida com valor de p &#8804; 0&#44;05&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Resultados</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Caracter&#237;sticas clinicopatol&#243;gicas</span><p id="par0095" class="elsevierStylePara elsevierViewall">No per&#237;odo do estudo&#44; 206 pacientes tiveram diagn&#243;stico de melanoma na regi&#227;o do tronco e foram selecionados para realiza&#231;&#227;o de BLNS em nossa institui&#231;&#227;o&#46; Desses&#44; 147 tiveram BLNS negativa e foram considerados eleg&#237;veis para o estudo&#46; Os pacientes que n&#227;o apresentavam informa&#231;&#245;es cl&#237;nicas ou patol&#243;gicas ou que n&#227;o cumpriram o tempo de seguimento exigido foram exclu&#237;dos&#44; e um total de 135 pacientes foi inclu&#237;do no estudo&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">As caracter&#237;sticas cl&#237;nicas dos pacientes e as caracter&#237;sticas patol&#243;gicas do melanoma prim&#225;rio&#44; de acordo com o padr&#227;o de drenagem linfonodal&#44; est&#227;o resumidas na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Setenta e oito pacientes &#40;57&#44;8&#37;&#41; eram do sexo masculino&#44; com mediana de idade de 69 anos &#40;33&#8208;95&#41;&#46; O melanoma estava localizado no tronco superior em 101 pacientes &#40;74&#44;8&#37;&#41;&#44; no tronco inferior em 34 &#40;25&#44;2&#37;&#41;&#44; no t&#243;rax em 32 &#40;23&#44;7&#37;&#41; e nas costas em 103 pacientes &#40;76&#44;3&#37;&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Os subtipos histol&#243;gicos de melanoma identificados foram extensivo superficial &#40;60&#41;&#44; nodular &#40;39&#41;&#44; nevoide &#40;1&#41;&#44; spitzoide &#40;1&#41;&#44; desmopl&#225;sico &#40;1&#41; ou outro &#40;7&#41;&#46; Em 26 casos faltou a classifica&#231;&#227;o do subtipo histol&#243;gico&#44; apesar de haver informa&#231;&#245;es sobre todas as outras vari&#225;veis estudadas&#46; A m&#233;dia da espessura de Breslow foi de 1&#44;7<span class="elsevierStyleHsp" style=""></span>mm&#44; e ulcera&#231;&#227;o estava presente em 47 &#40;34&#44;8&#37;&#41; pacientes&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Durante o per&#237;odo de seguimento&#44; tr&#234;s pacientes &#40;2&#37;&#41; tiveram apenas recidiva linfonodal&#44; 24 &#40;17&#44;8&#37;&#41; desenvolveram recidiva exclusivamente metast&#225;tica e nove &#40;6&#44;7&#37;&#41; tiveram recidiva linfonodal e metast&#225;tica&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A DBL m&#250;ltipla foi identificada em 61 &#40;45&#44;2&#37;&#41; pacientes&#44; e na maioria deles &#40;88&#44;5&#37;&#41; apenas duas bacias foram exploradas&#46; Em 35 &#40;57&#44;3&#37;&#41; pacientes com DBL m&#250;ltipla houve identifica&#231;&#227;o sim&#233;trica bilateral de LNS&#58; ambas as axilas em 30 &#40;46&#44;6&#37;&#41; pacientes e ambas as virilhas em cinco &#40;8&#44;2&#37;&#41;&#46; Em seis pacientes&#44; tr&#234;s bacias foram exploradas&#59; em um &#250;nico paciente ocorreu drenagem para quatro bacias&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Dos 74 pacientes com DBL &#250;nica&#44; o LNS estava localizado principalmente na axila &#40;63&#41;&#44; e menos frequentemente na virilha &#40;7&#41;&#44; &#225;rea cervical &#40;1&#41; ou outras bacias incomuns &#40;3&#59; escapular e supraclavicular&#41; &#8211; <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Os melanomas na regi&#227;o do tronco posterior foram mais frequentemente associados a DBL m&#250;ltipla &#40;51&#44;5&#37;&#41;&#44; enquanto melanomas na regi&#227;o do tronco anterior com DBL &#250;nica foram mais comuns &#40;75&#37;&#41;&#46; Essas diferen&#231;as foram consideradas estatisticamente significativas&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">N&#227;o encontramos nenhuma outra caracter&#237;stica cl&#237;nica ou histopatol&#243;gica significantemente associada ao padr&#227;o de drenagem &#40;DBL m&#250;ltipla e DBL &#250;nica&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Drenagem de bacia linf&#225;tica&#44; sobrevida livre de recidiva e risco de doen&#231;a</span><p id="par0140" class="elsevierStylePara elsevierViewall">O per&#237;odo m&#233;dio de seguimento foi de 5&#44;6 anos &#40;1&#8208;15 anos&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Dez dos 74 &#40;13&#44;5&#37;&#41; pacientes com DBL &#250;nica desenvolveram recorr&#234;ncia linfonodal&#44; em compara&#231;&#227;o com dois dos 61 &#40;3&#44;6&#37;&#41; pacientes com DBL m&#250;ltipla &#40;p &#61; 0&#44;04&#59; <a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a> e <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">No grupo de DBL &#250;nica&#44; cinco pacientes tiveram recorr&#234;ncia linfonodal na mesma bacia identificada na BLNS&#44; o que significa uma taxa de falso&#8208;negativo de BLNS de 6&#44;76&#37; &#40;5&#47;74&#41;&#46; Em outros cinco pacientes com DBL &#250;nica&#44; a recorr&#234;ncia linfonodal desenvolveu&#8208;se em uma bacia regional n&#227;o identificada na BLNS&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Nos dois pacientes com DBL m&#250;ltipla&#44; apenas um desenvolveu recidiva linfonodal em um territ&#243;rio n&#227;o previamente estudado pela BLNS&#44; o que significa uma taxa de falso&#8208;negativo de 1&#44;63&#37; &#40;1&#47;61&#41;&#46; A taxa geral de falso&#8208;negativo para BLNS foi de 4&#44;4&#37; &#40;6&#47;135&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Na an&#225;lise de sobrevida&#44; a SLR linfonodal foi significantemente mais longa no grupo com DBL m&#250;ltipla do que no grupo com DBL &#250;nica &#40;175&#44;6 <span class="elsevierStyleItalic">vs</span>&#46; 138&#44;7 meses&#59; p &#61; 0&#44;04&#59; <a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Na an&#225;lise univariada&#44; DBL &#250;nica &#40;HR &#61; 4&#44;34&#59; p &#61; 0&#44;05&#41; e espessura de Breslow &#40;HR &#61; 1&#44;36&#59; p &#61; 0&#44;05&#41; foram os &#250;nicos fatores significantemente associados a maior risco de recorr&#234;ncia linfonodal em pacientes com LNS negativo&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Ap&#243;s ajuste para espessura de Breslow&#44; a DBL &#250;nica permaneceu associada a maior risco de recorr&#234;ncia linfonodal &#40;HR &#61; 4&#44;54&#59; p &#61; 0&#44;05&#59; <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">Embora sem signific&#226;ncia estat&#237;stica&#44; houve tend&#234;ncia a menor risco de doen&#231;a linfonodal quando o n&#250;mero de bacias aumentou &#40;HR &#61; 0&#44;24&#59; p &#61; 0&#44;06&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">O n&#250;mero de linfonodos excisados n&#227;o se correlacionou com o risco de doen&#231;a linfonodal &#40;HR &#61; 0&#44;75&#59; p &#61; 0&#44;32&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">N&#227;o foram encontradas diferen&#231;as significativas na SLR metast&#225;tica e na SLR geral entre pacientes com DBL &#250;nica ou m&#250;ltipla &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; Na regress&#227;o log&#237;stica&#44; o padr&#227;o de drenagem linf&#225;tica n&#227;o afetou o risco de recorr&#234;ncia da doen&#231;a metast&#225;tica &#40;&#224; dist&#226;ncia&#41; ou geral &#40;linfonodal e metast&#225;tica&#59; p &#61; 0&#44;27 e p &#61; 0&#44;12&#44; respectivamente&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discuss&#227;o</span><p id="par0190" class="elsevierStylePara elsevierViewall">Diversos estudos avaliaram se a DBL m&#250;ltipla ou &#250;nica t&#234;m valor progn&#243;stico em rela&#231;&#227;o &#224; doen&#231;a linfonodal ou metast&#225;tica em pacientes com melanoma na regi&#227;o do tronco&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;10&#8211;16</span></a> Entretanto&#44; as conclus&#245;es s&#227;o divergentes&#44; o que pode estar relacionado &#224; inclus&#227;o de pacientes com BLNS positiva e negativa&#46; De fato&#44; sabe&#8208;se que a BLNS positiva &#233; um forte fator progn&#243;stico e&#44; para uma avalia&#231;&#227;o precisa&#44; esses grupos devem ser avaliados de maneira independente&#46; Apenas alguns pesquisadores analisaram o impacto do padr&#227;o de drenagem em pacientes com BLNS negativa&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8&#44;14&#44;15</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Devido aos resultados controversos&#44; avaliamos retrospectivamente uma s&#233;rie de casos de melanomas na regi&#227;o do tronco em pacientes com BLNS negativa&#46; Optamos por analisar melanomas na regi&#227;o do tronco por serem respons&#225;veis pela maioria das DBL&#8208;m&#250;ltiplas&#44; e selecionamos uma &#250;nica &#225;rea anat&#244;mica para reunir uma coorte mais homog&#234;nea de pacientes&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Na presente amostra&#44; foi observado que o risco de doen&#231;a linfonodal &#40;regional&#41; foi 4&#44;54 vezes maior no grupo com DBL &#250;nica do que no grupo DBL m&#250;ltipla&#44; enquanto nenhuma diferen&#231;a foi encontrada entre os grupos com doen&#231;a metast&#225;tica ou geral &#40;linfonodal e metast&#225;tica&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Em 2013&#44; Ribero et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> em um estudo de centro &#250;nico&#44; descobriram que&#44; em pacientes com melanoma na regi&#227;o do tronco e BLNS negativa&#44; a DBL &#250;nica estava associada a uma porcentagem maior de recorr&#234;ncia da doen&#231;a em compara&#231;&#227;o com DBL m&#250;ltipla &#40;19&#37; <span class="elsevierStyleItalic">vs</span>&#46; 7&#37;&#59; p &#61; 0&#44;03&#41;&#46; Entretanto&#44; os autores n&#227;o forneceram informa&#231;&#245;es sobre a recorr&#234;ncia da doen&#231;a linfonodal e metast&#225;tica&#44; separadamente&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Posteriormente&#44; em um estudo multic&#234;ntrico de 2016&#44; Ribero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> descobriram que&#44; em pacientes com BLNS negativa&#44; a DBL m&#250;ltipla estava associada a menor risco de recorr&#234;ncia do melanoma &#40;HR &#61; 0&#44;73&#59; p &#61; 0&#44;05&#41; e morte relacionada ao melanoma &#40;HR &#61; 0&#44;68&#59; p &#61; 0&#44;001&#41;&#44; embora n&#227;o houvesse diferen&#231;a na progress&#227;o linfonodal entre os grupos&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Ao contr&#225;rio&#44; Pinero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> mostraram que&#44; em pacientes com BLNS negativa&#44; a sobrevida livre de doen&#231;a &#40;linfonodal e metast&#225;tica&#41; era baixa em DBL m&#250;ltipla&#44; mas eles inclu&#237;ram melanomas de tronco e membros&#46; Investigar melanomas em diferentes &#225;reas anat&#244;micas&#44; que podem ter progn&#243;sticos gen&#233;ticos diferentes&#44; pode apresentar risco de vi&#233;s&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Jimenez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> relataram que pacientes com BLNS negativa em melanoma na regi&#227;o do tronco e DBL m&#250;ltipla tiveram uma SLR &#40;76 <span class="elsevierStyleItalic">vs</span>&#46; 190 meses para DBL &#250;nica&#44; p &#61; 0&#44;06&#41; e sobrevida global &#40;76 <span class="elsevierStyleItalic">vs</span>&#46; 190 meses para DBL &#250;nica&#44; p &#61; 0&#44;04&#41; menos favor&#225;veis&#46; Este estudo tem a limita&#231;&#227;o de um seguimento mediano mais curto &#40;27 meses&#41;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Com um tempo de seguimento mediano de mais de 5 anos&#44; nossos dados sugerem o conceito de que em pacientes com melanoma na regi&#227;o do tronco e BLNS negativa&#44; a DBL m&#250;ltipla est&#225; associada a um intervalo livre de recorr&#234;ncia nodal aumentado&#44; enquanto nenhuma diferen&#231;a em intervalos livres de doen&#231;a metast&#225;tica ou geral &#40;metast&#225;tica e linfonodal&#41; foi encontrada&#44; de acordo com o padr&#227;o de drenagem&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Nossa hip&#243;tese &#233; que&#44; em pacientes com DBL m&#250;ltipla&#44; uma BLNS negativa pode refletir melhor uma verdadeira aus&#234;ncia de doen&#231;a linfonodal &#8211; isto &#233;&#44; o valor preditivo negativo da BLNS pode ser maior&#44; uma vez que mais bacias foram avaliadas e a aus&#234;ncia de doen&#231;a foi documentada&#46; Em nossa amostra&#44; o desenvolvimento de doen&#231;a linfonodal em territ&#243;rio n&#227;o previamente estudado pela BLNS&#44; em metade dos casos com DBL &#250;nica&#44; pode corroborar essa hip&#243;tese&#44; evidenciando uma poss&#237;vel subestimativa de outras vias linf&#225;ticas com a linfocintilografia&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Uma possibilidade &#233; que a DBL &#250;nica possa ocorrer em decorr&#234;ncia da obstru&#231;&#227;o dos canais linf&#225;ticos pelas c&#233;lulas do melanoma&#44; impossibilitando o reconhecimento das rotas migrat&#243;rias na linfocintilografia&#44; levando &#224; BLNS negativa&#46; Embora a espessura de Breslow n&#227;o tenha sido significantemente diferente nos dois grupos&#44; a invas&#227;o linfovascular ou emboliza&#231;&#227;o n&#227;o foi avaliada&#44; n&#227;o sendo poss&#237;vel descartar esse fator como causa de tal diferen&#231;a&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Pode&#8208;se questionar a acur&#225;cia da linfocintilografia original&#44; mas encontramos uma taxa geral de falsos&#8208;negativos em torno de 4&#37;&#44; semelhante ou at&#233; menor do que os valores relatados em outras s&#233;ries &#40;4 a 10&#44;8&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8&#44;17</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">As limita&#231;&#245;es deste estudo incluem sua natureza de centro &#250;nico&#44; o pequeno tamanho da amostra e a an&#225;lise retrospectiva&#46; N&#227;o avaliamos a sobrevida global&#44; pois o estudo foi realizado em um per&#237;odo de 14 anos&#44; incluindo pacientes tratados de maneiras diferentes&#46; Com a recente introdu&#231;&#227;o de terapias direcionadas e imunoterapia&#44; houve uma melhora dram&#225;tica na sobrevida em compara&#231;&#227;o com os pacientes anteriores tratados com quimioterapia&#46; Se a sobrevida global tivesse sido comparada entre os grupos&#44; isso levaria a um vi&#233;s de tratamento&#46; Al&#233;m disso&#44; a avalia&#231;&#227;o histopatol&#243;gica da presen&#231;a de invas&#227;o linfovascular enriqueceria o presente estudo&#44; para corroborar nossa hip&#243;tese&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclus&#227;o</span><p id="par0250" class="elsevierStylePara elsevierViewall">A presen&#231;a de DBL m&#250;ltipla &#233; comum em pacientes com melanoma na regi&#227;o do tronco&#44; e em pacientes com BLNS negativa pode ser um fator de risco independente para recorr&#234;ncia da doen&#231;a linfonodal&#46; Embora o padr&#227;o de drenagem n&#227;o pare&#231;a influenciar a sobrevida livre de recorr&#234;ncia geral&#44; esse fator pode ajudar a identificar pacientes com BLNS negativa com maior risco de recorr&#234;ncia linfonodal&#44; inclusive em bacias n&#227;o estudadas anteriormente pela BLNS&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Suporte financeiro</span><p id="par0255" 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="par0260" class="elsevierStylePara elsevierViewall">Francisca Morgado&#58; Concep&#231;&#227;o e planeamento do estudo&#59; revis&#227;o cr&#237;tica da literatura&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o de dados&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">Paula Soeiro&#58; Obten&#231;&#227;o&#44; an&#225;lise&#44; e interpreta&#231;&#227;o de dados&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Ana Brinca&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e &#47; ou terap&#234;utica de casos estudados&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Andr&#233; Pinho&#58; An&#225;lise estat&#237;stica&#59; concep&#231;&#227;o e planejamento do estudo&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Ricardo Vieira&#58; Concep&#231;&#227;o e planejamento do estudo&#59; participa&#231;&#227;o intelectual na conduta proped&#234;utica e&#47;ou terap&#234;utica dos casos estudados&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflito de interesses</span><p id="par0285" 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">Existem dados conflitantes sobre o valor progn&#243;stico do padr&#227;o de drenagem da bacia linf&#225;tica em pacientes com melanoma&#44; e as evid&#234;ncias s&#227;o escassas no cen&#225;rio de bi&#243;psia de linfonodo sentinela negativa&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Investigar se o padr&#227;o de drenagem da bacia linf&#225;tica influencia no risco de doen&#231;a linfonodal em pacientes com melanoma na regi&#227;o do tronco e bi&#243;psia de linfonodo sentinela negativa&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Avaliamos retrospectivamente uma s&#233;rie de pacientes com melanomana regi&#227;o do tronco e bi&#243;psia de linfonodo sentinela negativa&#46; Revisamos as caracter&#237;sticas clinicopatol&#243;gicas&#44; o padr&#227;o de drenagem linf&#225;tica e a sobrevida livre de doen&#231;a linfonodal&#44; metast&#225;tica e recorr&#234;ncia geral&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nos 135 pacientes inclu&#237;dos no estudo&#44; a drenagem de m&#250;ltiplas bacias linf&#225;ticas foi identificada em 61 &#40;45&#44;2&#37;&#41;&#46; Dez dos 74 &#40;13&#44;5&#37;&#41; pacientes com drenagem &#250;nica desenvolveram recorr&#234;ncia linfonodal&#44; em compara&#231;&#227;o com 2 dos 61 &#40;3&#44;6&#37;&#41; pacientes com drenagem m&#250;ltipla &#40;p &#61; 0&#44;04&#41;&#46; A sobrevida livre de recorr&#234;ncia linfonodal foi significantemente maior no grupo com drenagem m&#250;ltipla do que no grupo com drenagem &#250;nica &#40;175&#44;6 <span class="elsevierStyleItalic">vs</span>&#46; 138&#44;7 meses&#59; p &#61; 0&#44;04&#41;&#46; Na an&#225;lise multivariada&#44; a drenagem &#250;nica foi associada ao maior risco de recorr&#234;ncia linfonodal &#40;HR &#61; 4&#44;54&#59; p &#61; 0&#44;05&#41;&#46; Nenhuma diferen&#231;a significante foi encontrada na sobrevida livre de doen&#231;a metast&#225;tica e recorr&#234;ncia geral entre os grupos&#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">An&#225;lise retrospectiva&#44; estudo de centro &#250;nico&#44; pequena amostra&#44; informa&#231;&#245;es histopatol&#243;gicas detalhadas nem sempre presentes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#245;es</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Em pacientes com melanoma da regi&#227;o do tronco e bi&#243;psia de linfonodo sentinela negativa&#44; a drenagem de m&#250;ltiplas bacias linf&#225;ticas pode ser um fator de risco independente para a recorr&#234;ncia da doen&#231;a linfonodal&#46; Esse fator pode ajudar a identificar pacientes com bi&#243;psia de linfonodo sentinela negativa com maior risco de recorr&#234;ncia linfonodal&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Subtipo histol&#243;gico</span></td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Extensivo superficial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nodular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nevoide&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Spitzoide&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Desmopl&#225;sico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Outro<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Desconhecido<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Localiza&#231;&#227;o</span></td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tronco superior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">59&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tronco inferior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;01<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anterior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">24 &#40;75&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;25&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Posterior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50 &#40;48&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">53 &#40;51&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;16&#44;7&#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">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">0&#44;04<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Qualquer recorr&#234;ncia metast&#225;tica &#40;distante&#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">21 &#40;63&#44;6&#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">12 &#40;36&#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">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">0&#44;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Qualquer recorr&#234;ncia da doen&#231;a &#40;geral&#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">24 &#40;66&#44;7&#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">12 &#40;33&#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">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">0&#44;09&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">DBL &#250;nica &#40;n &#61; 74&#41;</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">DBL m&#250;ltipla &#40;n &#61; 61&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2&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">3&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">4&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">Axila&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">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Axila&#44; bilateral&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">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&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">Virilha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Virilha&#44; bilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&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">Cervical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Axila &#43; virilha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">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">1&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">Incomum<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Axila &#43; cervical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Axila &#43; incomum<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cervical &#43; incomum<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&#250;ltipla incomum<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&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">2&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">&#8211;&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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fatores de risco para doen&#231;a linfonodal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;50&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;03&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">Localiza&#231;&#227;o&#58; tronco anterior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;93&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;36&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">Ulcera&#231;&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;90&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">DBL &#250;nica&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">4&#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
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                  \t\t\t\t">0&#44;05<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">N&#250;mero de bacias&nbsp;\t\t\t\t\t\t\n
                  \t\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&#44;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
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                  \t\t\t\t">0&#44;06&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
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                  \t\t\t\t">N&#250;mero de LS&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;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#44;54&nbsp;\t\t\t\t\t\t\n
                  \t\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&#44;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                      "titulo" => "ESMO consensus conference recommendations on the management of locoregional melanoma&#58; under the auspices of the ESMO Guidelines Committee"
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                            3 => "P&#46;A&#46; Ascierto"
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                      "doi" => "10.1016/j.annonc.2020.07.005"
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                        "volumen" => "31"
                        "paginaInicial" => "1449"
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                            4 => "R&#46;K&#46; Brookland"
                            5 => "M&#46;K&#46; Washington"
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                            3 => "N&#46; Mozzillo"
                            4 => "R&#46; Elashoff"
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                            3 => "J&#46;E&#46; Lee"
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                      "doi" => "10.1200/JCO.1999.17.3.976"
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                      "titulo" => "The role of preoperative lymphoscintigraphy in surgery planning for sentinel lymph node biopsy in malignant melanoma"
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                        "tituloSerie" => "Wien Klin Wochenschr&#46;"
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                      "titulo" => "Complete lymph node dissection versus no dissection in patients with sentinel lymph node biopsy positive melanoma &#40;DeCOG&#8208;SLT&#41;&#58; a multicentre&#44; randomised&#44; phase 3 trial"
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                          "autores" => array:6 [
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                            2 => "C&#46; Mauch"
                            3 => "W&#46; Hohenberger"
                            4 => "N&#46; Brockmeyer"
                            5 => "C&#46; Berking"
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                      "doi" => "10.1016/S1470-2045(16)00141-8"
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                        "tituloSerie" => "Lancet Oncol&#46;"
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                        "volumen" => "17"
                        "paginaInicial" => "757"
                        "paginaFinal" => "767"
                        "link" => array:1 [
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Article information
ISSN: 26662752
Original language: Portuguese
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