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relatada na literatura de que a CMM &#233; a melhor op&#231;&#227;o de tratamento para CBCs de alto risco que surgem na regi&#227;o da cabe&#231;a e pesco&#231;o ou s&#227;o recorrentes&#44; com uma taxa de recorr&#234;ncia de 3&#44;1&#37; com CMM <span class="elsevierStyleItalic">versus</span> 14&#37; com a cirurgia tradicional &#40;p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;00001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Estudos anteriores mostraram que as caracter&#237;sticas do tumor e do paciente podem prever um n&#250;mero maior de est&#225;gios necess&#225;rios para obter margens livres&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">4&#44;5</span></a> Subtipos histopatol&#243;gicos agressivos&#44; como micronodular&#44; infiltrativo e esclerodermiforme&#44; s&#227;o fatores bem conhecidos para um maior n&#250;mero de est&#225;gios e maiores margens livres de neoplasia&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> Em um estudo muito recente&#44; Cerci et al&#46; conclu&#237;ram que n&#227;o apenas os subtipos histopatol&#243;gicos micronodular&#44; infiltrativo e esclerodermiforme estavam associados a margens maiores&#44; mas tamb&#233;m o subtipo superficial &#40;em virtude da maior extens&#227;o subcl&#237;nica&#41;&#59; enquanto tumores clinicamente bem definidos e pequenos necessitavam de margens menores&#44; com tumores medindo &#60;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm&#44; mostrando uma taxa de margem livre de neoplasia 96&#37; com margens de 3<span class="elsevierStyleHsp" style=""></span>mm&#59; o tamanho pr&#233;&#8208;operat&#243;rio do tumor foi um preditor significativo de margens maiores e maior n&#250;mero de est&#225;gios da CMM&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Outro estudo retrospectivo recente avaliou as caracter&#237;sticas do carcinoma basocelular com grande extens&#227;o subcl&#237;nica &#40;BCC&#8208;LSE&#59; do ingl&#234;s&#44; <span class="elsevierStyleItalic">basal cell carcinoma with large subclinical extension</span>&#41;&#44; um tumor cuja extensa dissemina&#231;&#227;o torna&#8208;se aparente durante a revis&#227;o histopatol&#243;gica da cirurgia de Mohs&#46; De um total de 2&#46;044 casos que preencheram os crit&#233;rios de BCC&#8208;LSE &#40;definidos como uma les&#227;o que requer pelo menos tr&#234;s est&#225;gios de Mohs e uma margem cir&#250;rgica final &#8805; 10<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; sexo masculino &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; tipo de pele Fitzpatrick I &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#44; hist&#243;ria de CBC pr&#233;vio &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41; e subtipos basoescamoso&#44; metat&#237;pico&#44; micronodular&#44; infiltrativo&#44; esclerodermiforme e esclerosante &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#41; permaneceram preditores significativos de BCC&#8208;LSE&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Embora a CMM tenha demonstrado ser poupadora de tecido&#44; poucos estudos correlacionaram as margens necess&#225;rias para obter uma margem livre de neoplasia &#224;s caracter&#237;sticas do tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Recentemente&#44; Ariza et al&#46; demonstraram que uma margem de ressec&#231;&#227;o de 4<span class="elsevierStyleHsp" style=""></span>mm foi suficiente para erradicar completamente o tumor em 99&#37; dos casos de CBCs faciais prim&#225;rios pequenos &#40;&#8804; 6<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; mesmo com padr&#245;es histopatol&#243;gicos agressivos &#40;micronodular&#44; infiltrativo ou esclerodermiforme&#41;&#46; Margens menores que 2 e 3<span class="elsevierStyleHsp" style=""></span>mm obtiveram a ex&#233;rese completa da les&#227;o em 73&#44;9&#37; e 94&#44;4&#37; dos casos&#44; respectivamente&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Objetivos</span><p id="par0020" class="elsevierStylePara elsevierViewall">O objetivo principal deste estudo &#233; correlacionar as vari&#225;veis clinicopatol&#243;gicas dos pacientes e dos tumores com o n&#250;mero de est&#225;gios da CMM necess&#225;rios para a elimina&#231;&#227;o total do tumor&#46; Como desfecho secund&#225;rio&#44; pretende&#8208;se correlacionar as mesmas vari&#225;veis com as margens cir&#250;rgicas finais necess&#225;rias&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">M&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Foram estudados retrospectivamente os CBCs tratados por CMM no departamento onde o estudo foi realizado&#44; em um per&#237;odo de dois anos&#44; de julho de 2018 a julho de 2020&#46; Os dados foram coletados prospectivamente em cada procedimento e inclu&#237;ram caracter&#237;sticas do paciente &#40;sexo&#44; idade e estado imunol&#243;gico&#41;&#44; caracter&#237;sticas do tumor &#40;localiza&#231;&#227;o&#44; tumor prim&#225;rio&#47;recorrente&#47;persistente ou previamente submetido a ex&#233;rese incompleta&#44; tamanho&#44; subtipo histopatol&#243;gico&#44; presen&#231;a de invas&#227;o perineural&#41; e caracter&#237;sticas cir&#250;rgicas &#40;n&#250;mero de est&#225;gios cir&#250;rgicos e margens cir&#250;rgicas globais necess&#225;rias para alcan&#231;ar ex&#233;rese completa&#41;&#46; As margens cir&#250;rgicas globais s&#227;o definidas como a quantidade de tecido excisado al&#233;m dos limites cl&#237;nicos do tumor&#44; e s&#227;o expressas em mil&#237;metros&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A localiza&#231;&#227;o do tumor foi estratificada pelo risco de recorr&#234;ncia de acordo com a classifica&#231;&#227;o da National Comprehensive Cancer Network &#40;NCCN&#41; como de alto&#44; moderado e baixo risco&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> Em seguida&#44; quatro grandes &#225;reas de alto risco foram analisadas e comparadas &#40;isto &#233;&#44; periocular&#44; nariz&#44; perioral&#44; orelha&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Os CBCs foram classificados&#44; de acordo com os subtipos histopatol&#243;gicos&#44; em baixo risco &#40;superficial&#44; nodular&#44; trabecular e &#8220;misto de baixo risco&#8221;&#41; e alto risco &#40;micronodular&#44; infiltrativo&#44; esclerodermiforme&#44; metat&#237;pico e &#8220;misto de alto risco&#8221;&#41;&#46; Quando mais de um subtipo estava presente&#44; o CBC foi classificado com base no subtipo mais agressivo&#44; em um dos dois grupos&#58; &#8220;misto de alto risco&#8221; &#40;quando pelo menos um subtipo agressivo estava presente&#41; ou &#8220;misto de baixo risco&#8221; &#40;quando todos os subtipos eram de baixo risco&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Quando um tumor apresentou invas&#227;o perineural ou um subtipo histopatol&#243;gico de alto risco&#44; foi classificado como tendo uma histopatologia agressiva ou crit&#233;rios de alto risco&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Tanto a les&#227;o quanto o defeito cir&#250;rgico final ap&#243;s a CMM foram medidos&#44; com comprimento e largura relatados em mil&#237;metros&#46; Em seguida&#44; os di&#226;metros foram calculados como a m&#233;dia de comprimento e largura para defeito &#40;<span class="elsevierStyleItalic">D</span>&#41; e les&#227;o &#40;<span class="elsevierStyleItalic">d</span>&#41;&#46; A margem cir&#250;rgica final necess&#225;ria &#40;<span class="elsevierStyleItalic">m</span>&#41; foi calculada como a diferen&#231;a entre o di&#226;metro final do defeito &#40;<span class="elsevierStyleItalic">D</span>&#41; e o di&#226;metro da les&#227;o &#40;<span class="elsevierStyleItalic">d&#41; &#8211;</span><a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#46; As medidas foram realizadas por uma equipe fixa de cirurgi&#245;es com especializa&#231;&#227;o na cirurgia de Mohs e com experi&#234;ncia nessa &#225;rea&#44; utilizando o mesmo m&#233;todo&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">An&#225;lise estat&#237;stica</span><p id="par0050" class="elsevierStylePara elsevierViewall">Os dados foram analisados pelo software SPSS vers&#227;o 25 &#40;Armonk&#44; NY&#58; IBM Corp&#46;&#41; Ap&#243;s verificar a distribui&#231;&#227;o n&#227;o normal das vari&#225;veis&#44; foram realizados os testes de Mann&#8208;Whitney e Kruskal&#8208;Wallis para comparar o n&#250;mero de est&#225;gios da CMM e as margens finais com outras vari&#225;veis clinicopatol&#243;gicas&#44; seguido de an&#225;lise <span class="elsevierStyleItalic">post&#8208;hoc</span> para compara&#231;&#245;es m&#250;ltiplas&#46; A correla&#231;&#227;o de Spearman foi utilizada para correlacionar as vari&#225;veis quantitativas&#46; Um modelo de regress&#227;o linear foi utilizado para listar os preditores mais associados ao n&#250;mero de tempos de cirurgia&#46; Na estat&#237;stica descritiva&#44; os dados qualitativos s&#227;o apresentados como porcentagem &#40;&#37;&#41; e n&#250;mero &#40;n&#41;&#44; e os dados quantitativos com m&#233;dia e desvio padr&#227;o&#44; quando desej&#225;vel&#46; O n&#237;vel de signific&#226;ncia foi estabelecido em p &#8804; 0&#44;05&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Todos os pacientes assinaram um termo de consentimento livre e informado dando permiss&#227;o para o uso desses dados&#44; e a pesquisa foi conduzida de acordo com o Comit&#234; de &#201;tica local&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Caracteriza&#231;&#227;o da popula&#231;&#227;o e dos tumores</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">Foram inclu&#237;dos 116 CBCs&#44; em 113 pacientes &#40;60 mulheres e 53 homens&#41; com m&#233;dia de idade de 70 anos &#40;varia&#231;&#227;o de 31 a 92&#41;&#44; em uma popula&#231;&#227;o majoritariamente n&#227;o imunossuprimida &#40;87&#44;9&#37;&#41;&#46; Em m&#233;dia&#44; os CBCs mediam 14&#44;66<span class="elsevierStyleHsp" style=""></span>mm &#40;intervalo 4&#8208;58<span class="elsevierStyleHsp" style=""></span>mm&#41; e quase todos estavam localizados em &#225;reas de alto risco &#40;94&#44;8&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>110&#41;&#44; principalmente no nariz &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>77&#59; <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46; A maioria dos CBCs era de tumores prim&#225;rios &#40;63&#44;8&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>74&#41;&#44; 24&#44;1&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>28&#41; eram recorrentes e 12&#44;1&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#41; eram CBCs persistentes &#40;anteriormente submetidos a ex&#233;rese incompleta&#41;&#46; A maioria deles apresentava pelo menos um crit&#233;rio histopatol&#243;gico de alto risco &#40;74&#44;1&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>86&#41; relacionado a um subtipo histopatol&#243;gico agressivo em 73&#44;3&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>85&#41; ou invas&#227;o perineural em 3&#44;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Em rela&#231;&#227;o aos subtipos histopatol&#243;gicos de alto risco&#44; o mais comum foi o infiltrativo &#40;22&#44;4&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41;&#44; seguido pelo micronodular &#40;13&#44;8&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#41;&#44; metat&#237;pico &#40;5&#44;2&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41; e esclerodermiforme &#40;4&#44;3&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&#59; 32 casos &#40;27&#44;6&#37;&#41; eram mistos de alto risco &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Rela&#231;&#227;o entre vari&#225;veis clinicopatol&#243;gicas e n&#250;mero de est&#225;gios da CMM</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">A maioria dos CBCs &#40;61&#44;2&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>71&#41; necessitou de um &#250;nico est&#225;gio da cirurgia para remo&#231;&#227;o completa do tumor&#59; 31&#44;9&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>37&#41; precisaram de dois est&#225;gios&#44; 5&#44;2&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41; precisaram de tr&#234;s e apenas 0&#44;9&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; dos casos necessitou de quatro est&#225;gios&#44; com m&#233;dia de 1&#44;45 est&#225;gios &#40;&#177; 0&#44;64&#41;&#46; A <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a> resume a rela&#231;&#227;o das vari&#225;veis clinicopatol&#243;gicas com o n&#250;mero de est&#225;gios da CMM&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Embora os homens tenham exigido mais est&#225;gios do que as mulheres &#40;m&#233;dia de 1&#44;56 <span class="elsevierStyleItalic">versus</span> 1&#44;35&#41;&#44; isso n&#227;o foi estatisticamente significativo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;063&#41;&#46; A idade e o tamanho do tumor n&#227;o pareceram se correlacionar com o n&#250;mero de est&#225;gios necess&#225;rios &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8208;0&#44;035&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;707&#59; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;104&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;271&#41;&#46; Mesmo quando foram comparados tumores<span class="elsevierStyleHsp" style=""></span>&#62; 20<span class="elsevierStyleHsp" style=""></span>mm com aqueles &#8804; 20<span class="elsevierStyleHsp" style=""></span>mm&#44; n&#227;o foram encontradas diferen&#231;as estatisticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;263&#41;&#44; embora aqueles com d<span class="elsevierStyleHsp" style=""></span>&#62; 20<span class="elsevierStyleHsp" style=""></span>mm necessitassem de maior m&#233;dia de est&#225;gios cir&#250;rgicos &#40;1&#44;55 <span class="elsevierStyleItalic">versus</span> 1&#44;42&#41;&#46; Os imunossuprimidos apresentaram maior m&#233;dia de est&#225;gios da CMM &#40;1&#44;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;85&#41; do que os imunocompetentes &#40;1&#44;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;63&#41;&#44; embora isso n&#227;o fosse estatisticamente significativo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;838&#41;&#46; Tumores persistentes tiveram a maior m&#233;dia de est&#225;gios cir&#250;rgicos necess&#225;rios &#40;1&#44;86&#41;&#44; seguidos de tumores recorrentes &#40;1&#44;43&#41; e prim&#225;rios &#40;1&#44;38&#41;&#44; embora essas diferen&#231;as n&#227;o tenham signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;279&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Ao comparar as subunidades de alto risco&#44; ou seja&#44; &#225;rea periocular&#44; nariz&#44; &#225;rea perioral e orelha&#44; foi observada uma diferen&#231;a estatisticamente significativa no n&#250;mero de est&#225;gios da CMM necess&#225;rios para a ex&#233;rese completa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;025&#41;&#46; A <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a> mostra quais grupos espec&#237;ficos evidenciaram uma diferen&#231;a estatisticamente significativa&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Considerando os aspectos histopatol&#243;gicos&#44; ter uma histopatologia agressiva &#40;subtipo de alto risco ou invas&#227;o perineural&#41; influenciou de maneira significativa o n&#250;mero de est&#225;gios da CMM &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#41;&#46; Al&#233;m disso&#44; ao comparar os subtipos histopatol&#243;gicos de alto risco e baixo risco&#44; tamb&#233;m foi encontrada diferen&#231;a estatisticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#41;&#44; com subtipos de alto risco exigindo mais est&#225;gios cir&#250;rgicos &#40;m&#233;dia de 1&#44;55&#41; do que os subtipos de baixo risco &#40;m&#233;dia de 1&#44;19&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Ao realizar uma an&#225;lise multivariada com modelo de regress&#227;o linear&#44; concluiu&#8208;se que o n&#250;mero de est&#225;gios da CMM foi influenciado principalmente pela localiza&#231;&#227;o periocular do tumor &#40;p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e pelo subtipo histopatol&#243;gico de alto risco &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41;&#46; Ou seja&#44; em tumores perioculares&#44; o n&#250;mero de est&#225;gios da CMM aumenta em m&#233;dia 0&#44;89 vez&#46; Nos subtipos histopatol&#243;gicos de alto risco&#44; o n&#250;mero de est&#225;gios da CMM aumenta em m&#233;dia 0&#44;36 vez&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Correla&#231;&#227;o das vari&#225;veis clinicopatol&#243;gicas com as margens cir&#250;rgicas</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">O di&#226;metro m&#233;dio do defeito cir&#250;rgico final &#40;D&#41; foi de 20&#44;75<span class="elsevierStyleHsp" style=""></span>mm &#40;varia&#231;&#227;o 6&#44;5&#8211;60&#41;&#44; com m&#233;dia de 3&#44;11<span class="elsevierStyleHsp" style=""></span>mm para as margens cir&#250;rgicas finais necess&#225;rias &#40;m&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">N&#227;o foi encontrada uma rela&#231;&#227;o significante entre as caracter&#237;sticas cl&#237;nicas ou histopatol&#243;gicas estudadas e a varia&#231;&#227;o das margens cir&#250;rgicas finais &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Embora os homens necessitassem de margens maiores para a remo&#231;&#227;o completa do tumor do que as mulheres &#40;m&#233;dia de 3&#44;25 <span class="elsevierStyleItalic">versus</span> 2&#44;99<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; isso n&#227;o foi estatisticamente significativo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;985&#41;&#46; Nem a idade do paciente&#44; nem a dimens&#227;o do tumor se correlacionaram de maneira significativa com as margens cir&#250;rgicas finais &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;118&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;227&#59; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;029&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;766&#41;&#46; Tumores<span class="elsevierStyleHsp" style=""></span>&#62; 20<span class="elsevierStyleHsp" style=""></span>mm exigiram margens cir&#250;rgicas maiores &#40;m&#233;dia 4&#44;22<span class="elsevierStyleHsp" style=""></span>mm&#41; do que aqueles medindo &#8804; 20<span class="elsevierStyleHsp" style=""></span>mm &#40;m&#233;dia 2&#44;88<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; mas novamente sem signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;166&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Tumores persistentes apresentaram a maior m&#233;dia de margens cir&#250;rgicas necess&#225;rias para ex&#233;rese completa &#40;4&#44;27<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; seguidos de tumores recorrentes &#40;3&#44;71<span class="elsevierStyleHsp" style=""></span>mm&#41; e prim&#225;rios &#40;2&#44;68<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; embora essas diferen&#231;as n&#227;o tenham demonstrado signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;234&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Tumores na regi&#227;o periocular necessitaram das maiores margens &#40;m&#233;dia de 4&#44;55<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; seguidos de tumores na regi&#227;o perioral &#40;m&#233;dia de 2&#44;93<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; nariz &#40;m&#233;dia de 2&#44;80<span class="elsevierStyleHsp" style=""></span>mm&#41; e orelha &#40;m&#233;dia de 2&#44;36<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; embora as diferen&#231;as n&#227;o tenham sido estatisticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;811&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Margens cir&#250;rgicas maiores foram necess&#225;rias quando havia crit&#233;rios histopatol&#243;gicos de alto risco &#40;m&#233;dia 3&#44;23 <span class="elsevierStyleItalic">versus</span> 2&#44;72<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; mas isso n&#227;o foi estatisticamente significativo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;837&#41;&#46; Al&#233;m disso&#44; apesar de n&#227;o haver signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;936&#41;&#44; as margens aumentam com o aumento do n&#250;mero de crit&#233;rios histopatol&#243;gicos de alto risco&#44; com m&#233;dia de 2&#44;74<span class="elsevierStyleHsp" style=""></span>mm se n&#227;o houver fatores de risco histopatol&#243;gicos&#44; 3&#44;23<span class="elsevierStyleHsp" style=""></span>mm se houver e 3&#44;33<span class="elsevierStyleHsp" style=""></span>mm quando h&#225; dois fatores&#46; Comparando os subtipos histopatol&#243;gicos de alto e baixo risco&#44; houve diferen&#231;as &#40;subtipos de alto risco levaram a um aumento m&#233;dio de margem de 3&#44;23<span class="elsevierStyleHsp" style=""></span>mm&#44; enquanto os de baixo risco&#44; de 2&#44;74<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; mas n&#227;o foram estatisticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;933&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">4&#41; Aspectos cir&#250;rgicos</p><p id="par0150" class="elsevierStylePara elsevierViewall">A redu&#231;&#227;o do volume tumoral &#40;<span class="elsevierStyleItalic">debulking</span>&#41; foi realizada em quase todos os casos &#40;87&#44;1&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>101&#41;&#46; A maioria dos defeitos cir&#250;rgicos necessitou de retalho para reconstru&#231;&#227;o &#40;79&#44;3&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>92&#41;&#44; principalmente de avan&#231;o &#40;40&#44;5&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>47&#41;&#44; seguido de transposi&#231;&#227;o &#40;30&#44;2&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>35&#41; e rota&#231;&#227;o &#40;8&#44;6&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46; Em 12 pacientes &#40;10&#44;3&#37;&#41; foi poss&#237;vel o fechamento direto&#59; em sete &#40;6&#37;&#41; foi utilizado enxerto de pele de espessura total&#59; em um &#40;0&#44;9&#37;&#41; utilizou&#8208;se enxerto composto&#59; e quatro defeitos cir&#250;rgicos &#40;3&#44;4&#37;&#41; foram submetidos &#224; cicatriza&#231;&#227;o por segunda inten&#231;&#227;o&#46; Foi encontrada uma taxa de recorr&#234;ncia de 1&#44;7&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; com tempo m&#233;dio de seguimento de 13&#44;37 meses &#40;varia&#231;&#227;o 2&#8208;27&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discuss&#227;o</span><p id="par0155" class="elsevierStylePara elsevierViewall">O presente estudo teve como objetivo correlacionar as caracter&#237;sticas clinicopatol&#243;gicas pr&#233;&#8208;operat&#243;rias dos CBCs com o n&#250;mero de est&#225;gios da CMM &#40;desfecho prim&#225;rio&#41; e a extens&#227;o das margens cir&#250;rgicas p&#243;s&#8208;operat&#243;rias &#40;desfecho secund&#225;rio&#41; necess&#225;rios para a elimina&#231;&#227;o total do tumor&#46; Idealmente&#44; isso poderia ajudar a identificar quais tumores devem ser submetidos a um procedimento cir&#250;rgico mais cuidadoso e&#44; eventualmente&#44; maiores margens iniciais na CMM&#46; Em rela&#231;&#227;o ao n&#250;mero de est&#225;gios da CMM&#44; foi encontrada uma associa&#231;&#227;o significativa com subtipo histopatol&#243;gico de alto risco&#44; histopatologia agressiva e localiza&#231;&#227;o&#46; Entretanto&#44; em rela&#231;&#227;o &#224; margem lateral final&#44; foi encontrada apenas uma tend&#234;ncia para seu aumento com algumas vari&#225;veis&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">A maioria dos CBCs submetidos &#224; CMM no presente estudo mediam<span class="elsevierStyleHsp" style=""></span>&#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#44; estavam localizados principalmente em &#225;reas de alto risco ou apresentavam pelo menos um crit&#233;rio histopatol&#243;gico de alto risco&#44; o que est&#225; de acordo com as principais indica&#231;&#245;es para esse tipo de cirurgia&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Na maioria dos casos&#44; foi necess&#225;rio apenas um est&#225;gio da CMM&#46; Os homens necessitaram de mais est&#225;gios do que as mulheres&#44; aproximando&#8208;se da signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;063&#41;&#44; embora sem alcan&#231;&#225;&#8208;la&#46; Imunossupress&#227;o&#44; idade do paciente e tamanho do tumor n&#227;o influenciaram de maneira significativa o n&#250;mero de est&#225;gios da CMM na presente amostra&#46; Isso est&#225; em desacordo com outros estudos&#44; nos quais o tamanho pr&#233;&#8208;operat&#243;rio do tumor foi um preditor significativo de margens maiores e n&#250;mero de est&#225;gios&#44; especialmente quando<span class="elsevierStyleHsp" style=""></span>&#62; 20<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">7&#44;10&#44;11</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Embora sem signific&#226;ncia estat&#237;stica&#44; os tumores persistentes tiveram a maior m&#233;dia de est&#225;gios cir&#250;rgicos necess&#225;rios&#44; seguidos por tumores recorrentes e prim&#225;rios&#46; Outros estudos tamb&#233;m mostraram que tumores recorrentes precisam de mais est&#225;gios cir&#250;rgicos do que os prim&#225;rios&#44; mas n&#227;o avaliaram tumores persistentes&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Em rela&#231;&#227;o &#224; localiza&#231;&#227;o de alto risco&#44; h&#225; uma diferen&#231;a estatisticamente significativa em rela&#231;&#227;o ao n&#250;mero de est&#225;gios entre os tumores localizados na regi&#227;o periocular e aqueles localizados na orelha&#44; nariz ou &#225;rea perioral &#8211; os CBCs perioculares requerem mais est&#225;gios de cirurgia&#46; Embora a localiza&#231;&#227;o em &#225;reas de alto risco tenha se mostrado associada a maior n&#250;mero de est&#225;gios em estudos anteriores&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">4&#44;5&#44;7</span></a> a especifica&#231;&#227;o e a compara&#231;&#227;o entre v&#225;rias &#225;reas de alto risco s&#227;o mais raramente mencionadas na literatura&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Ter uma histopatologia agressiva &#40;seja subtipo de alto risco ou invas&#227;o perineural&#41; influenciou de maneira significativa o n&#250;mero de est&#225;gios da CMM&#44; e os subtipos de alto risco &#40;micronodular&#44; infiltrativo&#44; esclerodermiforme&#44; metat&#237;pico e &#8220;misto de alto risco&#8221;&#41; exigiram mais est&#225;gios cir&#250;rgicos do que os de baixo risco &#40;superficial&#44; nodular&#44; trabecular e &#8220;misto de baixo risco&#8221;&#41;&#44; o que est&#225; de acordo com outros estudos&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> Ao avaliar os subtipos histopatol&#243;gicos de baixo risco&#44; os CBCs superficiais apresentaram a maior m&#233;dia de est&#225;gios da CMM&#46; Isso est&#225; de acordo com um estudo recente de Cerci et al&#46;&#44; que mostrou que n&#227;o apenas os subtipos micronodular&#44; infiltrativo e esclerodermiforme&#44; mas tamb&#233;m o superficial&#44; estavam associados a margens maiores&#44; concluindo que os CBCs superficiais tinham maior extens&#227;o subcl&#237;nica&#44; levando a margens maiores e mais est&#225;gios cir&#250;rgicos&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Al&#233;m disso&#44; em 2013&#44; um grupo de dermatologistas e cirurgi&#245;es de cabe&#231;a e pesco&#231;o categorizou os CBCs superficiais como grupo histopatol&#243;gico de alto risco em virtude de seu padr&#227;o de crescimento irregular&#44; acarretando um maior risco de ex&#233;rese incompleta&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Tamb&#233;m foi avaliada a influ&#234;ncia dos mesmos fatores clinicopatol&#243;gicos nas margens cir&#250;rgicas necess&#225;rias para a remo&#231;&#227;o tumoral&#44; mas n&#227;o foi encontrada uma rela&#231;&#227;o estatisticamente significativa entre eles&#44; apenas algumas tend&#234;ncias&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Pode&#8208;se imaginar os tumores e defeitos cir&#250;rgicos como perfeitamente redondos&#44; mas na pr&#225;tica isso raramente acontece&#46; A configura&#231;&#227;o do defeito final costuma ser diferente da do tumor prim&#225;rio&#44; e os incrementos em comprimento e largura nem sempre s&#227;o harmoniosos ou sim&#233;tricos&#44; o que torna essa avalia&#231;&#227;o particularmente dif&#237;cil&#46; Al&#233;m disso&#44; deve&#8208;se levar em considera&#231;&#227;o que a t&#233;cnica utilizada para medir as margens de ex&#233;rese varia muito entre os autores&#44; e &#233; especialmente dif&#237;cil avali&#225;&#8208;la com precis&#227;o&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Apesar disso&#44; na literatura&#44; Cerci et al&#46; recentemente descobriram que CBCs medindo &#60;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm tinham uma taxa de elimina&#231;&#227;o de 96&#37; com margens &#8804; 3<span class="elsevierStyleHsp" style=""></span>mm&#46; Eles tamb&#233;m descobriram que os subtipos histopatol&#243;gicos superficial&#44; micronodular&#44; infiltrativo e esclerodermiforme estavam associados a margens maiores &#40;m&#233;dia de 3&#44;1&#44; 3&#44;9&#44; 2&#44;7 e 4<span class="elsevierStyleHsp" style=""></span>mm&#44; respectivamente&#41;&#44; enquanto tumores clinicamente bem definidos foram associados a margens menores &#40;m&#233;dia de 1&#44;9<span class="elsevierStyleHsp" style=""></span>mm <span class="elsevierStyleItalic">versus</span> 2&#44;9<span class="elsevierStyleHsp" style=""></span>mm para tumores mal definidos&#41;&#46; Curiosamente&#44; entretanto&#44; a localiza&#231;&#227;o em &#225;reas de alto risco n&#227;o foi associada de maneira significante a margens maiores&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Em outro estudo recente com 306 CBCs pequenos e agressivos na face &#40;definidos como tumores com &#60;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm na &#225;rea H e &#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mm na &#225;rea M&#41;&#44; as margens necess&#225;rias para a elimina&#231;&#227;o do tumor tamb&#233;m foram avaliadas&#46; Eles tamb&#233;m descobriram que 94&#44;9&#37; dos tumores medindo &#60;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm foram eliminados com margens de 3<span class="elsevierStyleHsp" style=""></span>mm e que uma margem de ressec&#231;&#227;o de 4<span class="elsevierStyleHsp" style=""></span>mm foi suficiente para realizar a ex&#233;rese completa da les&#227;o em 99&#37; dos casos de pequenos CBCs faciais prim&#225;rios com subtipos histopatol&#243;gicos agressivos&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Em um estudo anterior de Schell et al&#46; incluindo 385 CBCs&#44; margens m&#233;dias de 2&#44;4<span class="elsevierStyleHsp" style=""></span>mm e 3&#44;7<span class="elsevierStyleHsp" style=""></span>mm foram encontradas para tumores de baixo e alto risco&#44; respectivamente&#44; com margens de 4&#44;75<span class="elsevierStyleHsp" style=""></span>mm e 8<span class="elsevierStyleHsp" style=""></span>mm atingindo 95&#37; de elimina&#231;&#227;o do tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Observou&#8208;se uma taxa de recidiva menor do que aquela relatada na literatura &#40;3&#44;1&#37;&#8208;4&#44;9&#37;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3&#44;12&#44;13</span></a> o que n&#227;o deve ser valorizado em raz&#227;o do curto tempo de seguimento dos pacientes do presente estudo no momento em que o artigo estava sendo escrito&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Import&#226;ncia do estudo e novidades</span><p id="par0215" class="elsevierStylePara elsevierViewall">A import&#226;ncia do presente estudo reside em sua relev&#226;ncia cl&#237;nica&#44; uma vez que correlacionar as caracter&#237;sticas clinicopatol&#243;gicas pr&#233;&#8208;operat&#243;rias com ambos os est&#225;gios da CMM e as margens cir&#250;rgicas p&#243;s&#8208;operat&#243;rias pode ajudar a prever quais tumores ir&#227;o necessitar de um procedimento cir&#250;rgico mais cuidadoso e&#44; de maneira ideal&#44; orientar as margens cir&#250;rgicas iniciais na CMM&#46; Isso poderia ajudar a evitar tempos cir&#250;rgicos prolongados&#44; reduzindo n&#227;o apenas a morbidade cir&#250;rgica&#44; mas tamb&#233;m o tempo e os custos&#46; A CMM &#233; uma t&#233;cnica cir&#250;rgica altamente especializada e muito &#250;til&#44; mas demorada<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> e que requer treinamento&#44; pessoal e equipamentos especializados&#44; o que acarreta custos aumentados quando s&#227;o necess&#225;rios tempos cir&#250;rgicos extras&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">No presente estudo&#44; os principais fatores relacionados ao maior n&#250;mero de est&#225;gios da CMM foram a localiza&#231;&#227;o periocular do tumor&#44; ter uma histopatologia agressiva e subtipos histopatol&#243;gicos de alto risco&#46; Al&#233;m disso&#44; na literatura h&#225; poucos estudos abordando as margens necess&#225;rias para a remo&#231;&#227;o completa do CBC utilizando a CMM&#46; Em rela&#231;&#227;o a esse aspecto&#44; entretanto&#44; n&#227;o foi encontrada nenhuma vari&#225;vel capaz de predizer esse aumento&#44; o que pode decorrer das limita&#231;&#245;es do estudo&#46; No presente estudo&#44; a localiza&#231;&#227;o em &#225;reas de alto risco foi associada a maior n&#250;mero de est&#225;gios&#44; o que confirma o que havia sido relatado anteriormente na literatura&#46; O que &#233; novo &#233; a diferen&#231;a estatisticamente significativa no n&#250;mero de est&#225;gios entre tumores localizados na regi&#227;o periocular e tumores localizados na orelha&#44; nariz ou &#225;rea perioral &#40;todos considerados &#225;reas de alto risco&#41;&#44; com CBCs perioculares exigindo mais est&#225;gios de cirurgia&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Al&#233;m disso&#44; at&#233; onde foi poss&#237;vel investigar na literatura&#44; a maioria dos estudos compara tumores prim&#225;rios e recorrentes&#44; mas n&#227;o avalia os persistentes &#40;tumores anteriormente submetidos a ex&#233;rese incompleta&#41;&#46; Na presente amostra&#44; os tumores persistentes apresentaram a maior m&#233;dia de est&#225;gios cir&#250;rgicos necess&#225;rios&#44; seguidos pelos tumores recorrentes e prim&#225;rios&#44; mas sem signific&#226;ncia estat&#237;stica&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Limita&#231;&#245;es do estudo</span><p id="par0230" class="elsevierStylePara elsevierViewall">As limita&#231;&#245;es do presente estudo incluem sua natureza de centro &#250;nico com um pequeno tamanho amostral&#44; o que limita o valor das conclus&#245;es&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Al&#233;m disso&#44; como explicado anteriormente&#44; o m&#233;todo utilizado para medir os tumores e defeitos cir&#250;rgicos n&#227;o &#233; preciso e difere de outros m&#233;todos utilizados na literatura &#40;p&#46; ex&#46;&#44; muitos autores utilizam o eixo principal da les&#227;o em vez da m&#233;dia de comprimento e largura&#41;&#46; Isso pode explicar&#44; pelo menos em parte&#44; as dificuldades encontradas em estabelecer rela&#231;&#245;es estatisticamente significativas em rela&#231;&#227;o &#224;s margens cir&#250;rgicas finais&#46; No futuro ser&#225; &#250;til encontrar um m&#233;todo mais preciso e universal para se obter essas medidas&#44; que devem&#44; de maneira ideal&#44; incluir a profundidade da les&#227;o&#44; dando&#8208;lhe uma vis&#227;o tridimensional &#40;3D&#41;&#44; mais pr&#243;xima da realidade&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclus&#227;o</span><p id="par0240" class="elsevierStylePara elsevierViewall">No presente estudo&#44; os principais fatores relacionados ao maior n&#250;mero de est&#225;gios da CMM foram a localiza&#231;&#227;o periocular do tumor e os subtipos histopatol&#243;gicos de alto risco &#40;micronodular&#44; infiltrativo&#44; esclerodermiforme&#44; metat&#237;pico e &#8220;misto de alto risco&#8221;&#41;&#46; Nenhum dos outros fatores estudados mostrou influenciar estatisticamente o n&#250;mero de est&#225;gios da CMM&#46; N&#227;o foi encontrada nenhuma vari&#225;vel capaz de predizer o aumento da margem final necess&#225;ria para a ex&#233;rese completa&#44; o que pode ser decorrente do tamanho relativamente pequeno da amostra do estudo ou da limita&#231;&#227;o t&#233;cnica da medida do incremento de margem&#46; Estudos prospectivos maiores seriam ben&#233;ficos para corroborar esses resultados&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Suporte financeiro</span><p id="par0245" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Contribui&#231;&#227;o dos autores</span><p id="par0250" class="elsevierStylePara elsevierViewall">Joana Calv&#227;o&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; revis&#227;o cr&#237;tica da literatura&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica do manuscrito&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; an&#225;lise estat&#237;stica&#59; concep&#231;&#227;o e planejamento do estudo&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Andr&#233; Pinho&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica do manuscrito&#59; an&#225;lise estat&#237;stica&#59; concep&#231;&#227;o e planejamento do estudo&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Ana Brinca&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">Ricardo Vieira&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflito de interesses</span><p id="par0270" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Agradecimentos</span><p id="par0275" class="elsevierStylePara elsevierViewall">Os autores agradecem &#224; Dra&#46; Margarida Marques por sua ajuda com a an&#225;lise estat&#237;stica&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Fundamentos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A cirurgia microgr&#225;fica de Mohs &#40;CMM&#41; &#233; comumente utilizada para tratar o carcinoma basocelular &#40;CBC&#41; de alto risco&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Correlacionar as caracter&#237;sticas clinicopatol&#243;gicas pr&#233;&#8208;operat&#243;rias com o n&#250;mero de est&#225;gios da CMM &#40;desfecho prim&#225;rio&#41; e margens cir&#250;rgicas &#40;desfecho secund&#225;rio&#41; necess&#225;rios para a ex&#233;rese completa do CBC&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Foram analisados retrospectivamente os CBCs tratados com CMM no per&#237;odo de dois anos&#46; As vari&#225;veis estudadas inclu&#237;ram sexo&#44; idade e estado imunol&#243;gico&#44; tamanho da les&#227;o&#44; localiza&#231;&#227;o&#44; se era tumor prim&#225;rio&#44; recorrente ou persistente&#44; caracter&#237;sticas histopatol&#243;gicas&#44; n&#250;mero de est&#225;gios cir&#250;rgicos e quantidade de tecido excisado&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Um total de 116 CBCs foram inclu&#237;dos&#46; A maioria &#40;61&#44;2&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>71&#41; necessitou de cirurgia em est&#225;gio &#250;nico para ex&#233;rese completa&#44; exigindo margem final de 3&#44;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;35<span class="elsevierStyleHsp" style=""></span>mm&#46; Foram encontradas diferen&#231;as estatisticamente significantes entre a localiza&#231;&#227;o em diferentes &#225;reas de alto risco &#40;periocular&#44; perioral&#44; nariz&#44; orelha&#41; e o n&#250;mero de est&#225;gios da CMM necess&#225;rios para a ex&#233;rese completa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;025&#41;&#44; com tumores perioculares exigindo a maior m&#233;dia de est&#225;gios &#40;2&#44;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;95&#41;&#46; A presen&#231;a de caracter&#237;sticas histopatol&#243;gicas indicativas de comportamento agressivo influenciou significantemente o n&#250;mero de est&#225;gios da CMM &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#41;&#46; N&#227;o foi encontrada rela&#231;&#227;o significante entre as caracter&#237;sticas clinicopatol&#243;gicas e varia&#231;&#227;o nas margens cir&#250;rgicas finais&#44; apenas algumas tend&#234;ncias &#40;pacientes do sexo masculino&#44; tumores persistentes&#44; perioculares e histopatologia de alto risco exigiram margens maiores&#41;&#46; Nem a idade do paciente&#44; nem a dimens&#227;o do tumor apresentaram correla&#231;&#227;o significante com o n&#250;mero de est&#225;gios da CMM e margens cir&#250;rgicas finais&#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">As limita&#231;&#245;es deste estudo incluem sua natureza de centro &#250;nico com pequeno tamanho de amostra&#44; o que limita o valor das conclus&#245;es&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Os principais fatores relacionados ao maior n&#250;mero de est&#225;gios da CMM foram a localiza&#231;&#227;o periocular e o subtipo histopatol&#243;gico de alto risco do tumor&#46;</p></span>"
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                  \t\t\t\t">4&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">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">2&#44;6&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">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;7&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">1&#44;7&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">2&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"><span class="elsevierStyleHsp" style=""></span>Superficial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">116</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">100</span>&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">mm&#44; mil&#237;metros&#59; DP&#44; desvio padr&#227;o&#59; MN&#44; micronodular&#59; I&#44; infiltrativo&#59; ESC&#44; esclerodermiforme&#59; MT&#44; metat&#237;pico&#59; MAR&#44; misto de alto risco&#59; S&#44; superficial&#59; N&#44; nodular&#59; T&#44; trabecular&#59; MBR&#44; misto de baixo risco&#46;</p>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Feminino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;35 &#40;&#177; 0&#44;58&#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&#44;99 &#40;&#177; 1&#44;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Imunossupress&#227;o</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;838&nbsp;\t\t\t\t\t\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">0&#44;969&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>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 &#40;&#177; 0&#44;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;00 &#40;&#177; 2&#44;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;46 &#40;&#177; 0&#44;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;14 &#40;&#177; 2&#44;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tumor prim&#225;rio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;38 &#40;&#177; 0&#44;51&#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  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;279</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;68 &#40;&#177; 1&#44;56&#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  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;234</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>Tumor recorrente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;43 &#40;&#177; 0&#44;63&#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">3&#44;71 &#40;&#177; 3&#44;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tumor persistente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;86 &#40;&#177; 1&#44;03&#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">4&#44;27 &#40;&#177; 3&#44;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Localiza&#231;&#227;o&#47;subunidade</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;025<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a></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  " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;811</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>Periocular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;29 &#40;&#177; 0&#44;95&#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">4&#44;55 &#40;&#177; 3&#44;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nariz&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;42 &#40;&#177; 0&#44;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;80 &#40;&#177; 1&#44;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Perioral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;36 &#40;&#177; 0&#44;67&#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&#44;93 &#40;&#177; 2&#44;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Orelha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;25 &#40;&#177; 0&#44;46&#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&#44;36 &#40;&#177; 1&#44;07&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Histopatologia agressiva</span><span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;012</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a></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  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;837</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>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;54 &#40;&#177; 0&#44;68&#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">3&#44;23 &#40;&#177; 2&#44;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;20 &#40;&#177; 0&#44;41&#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&#44;72 &#40;&#177; 1&#44;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Subtipo histopatol&#243;gico</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="12" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;008</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a></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  " rowspan="12" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;933</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alto risco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;55 &#40;</span>&#177; <span class="elsevierStyleBold">0&#44;68&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">3&#44;23 &#40;</span>&#177; <span class="elsevierStyleBold">2&#44;62&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;44 &#40;&#177; 0&#44;63&#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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Periocular &#42; orelha&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\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Perioral &#42; orelha&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;36 &#42; 1&#44;25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;000&nbsp;\t\t\t\t\t\t\n
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Artigo original
Fatores clinicopatológicos que influenciam o número de estágios da cirurgia de Mohs para carcinoma basocelular
Joana Calvãoa,
Corresponding author
11361@chuc.min-saude.pt

Autor para correspondência.
, André Pinhoa,b, Ana Brincaa,b, Ricardo Vieirab
a Departamento de Dermatovenerologia, Hospital Universitário de Coimbra, Coimbra, Portugal
b Faculdade de Medicina, Hospital Universitário de Coimbra, Coimbra, Portugal
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do ingl&#234;s&#44; <span class="elsevierStyleItalic">basal cell carcinoma with large subclinical extension</span>&#41;&#44; um tumor cuja extensa dissemina&#231;&#227;o torna&#8208;se aparente durante a revis&#227;o histopatol&#243;gica da cirurgia de Mohs&#46; De um total de 2&#46;044 casos que preencheram os crit&#233;rios de BCC&#8208;LSE &#40;definidos como uma les&#227;o que requer pelo menos tr&#234;s est&#225;gios de Mohs e uma margem cir&#250;rgica final &#8805; 10<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; sexo masculino &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; tipo de pele Fitzpatrick I &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#44; hist&#243;ria de CBC pr&#233;vio &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41; e subtipos basoescamoso&#44; metat&#237;pico&#44; micronodular&#44; infiltrativo&#44; esclerodermiforme e esclerosante &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#41; permaneceram preditores significativos de BCC&#8208;LSE&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Embora a CMM tenha demonstrado ser poupadora de tecido&#44; poucos estudos correlacionaram as margens necess&#225;rias para obter uma margem livre de neoplasia &#224;s caracter&#237;sticas do tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Recentemente&#44; Ariza et al&#46; demonstraram que uma margem de ressec&#231;&#227;o de 4<span class="elsevierStyleHsp" style=""></span>mm foi suficiente para erradicar completamente o tumor em 99&#37; dos casos de CBCs faciais prim&#225;rios pequenos &#40;&#8804; 6<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; mesmo com padr&#245;es histopatol&#243;gicos agressivos &#40;micronodular&#44; infiltrativo ou esclerodermiforme&#41;&#46; Margens menores que 2 e 3<span class="elsevierStyleHsp" style=""></span>mm obtiveram a ex&#233;rese completa da les&#227;o em 73&#44;9&#37; e 94&#44;4&#37; dos casos&#44; respectivamente&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Objetivos</span><p id="par0020" class="elsevierStylePara elsevierViewall">O objetivo principal deste estudo &#233; correlacionar as vari&#225;veis clinicopatol&#243;gicas dos pacientes e dos tumores com o n&#250;mero de est&#225;gios da CMM necess&#225;rios para a elimina&#231;&#227;o total do tumor&#46; Como desfecho secund&#225;rio&#44; pretende&#8208;se correlacionar as mesmas vari&#225;veis com as margens cir&#250;rgicas finais necess&#225;rias&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">M&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Foram estudados retrospectivamente os CBCs tratados por CMM no departamento onde o estudo foi realizado&#44; em um per&#237;odo de dois anos&#44; de julho de 2018 a julho de 2020&#46; Os dados foram coletados prospectivamente em cada procedimento e inclu&#237;ram caracter&#237;sticas do paciente &#40;sexo&#44; idade e estado imunol&#243;gico&#41;&#44; caracter&#237;sticas do tumor &#40;localiza&#231;&#227;o&#44; tumor prim&#225;rio&#47;recorrente&#47;persistente ou previamente submetido a ex&#233;rese incompleta&#44; tamanho&#44; subtipo histopatol&#243;gico&#44; presen&#231;a de invas&#227;o perineural&#41; e caracter&#237;sticas cir&#250;rgicas &#40;n&#250;mero de est&#225;gios cir&#250;rgicos e margens cir&#250;rgicas globais necess&#225;rias para alcan&#231;ar ex&#233;rese completa&#41;&#46; As margens cir&#250;rgicas globais s&#227;o definidas como a quantidade de tecido excisado al&#233;m dos limites cl&#237;nicos do tumor&#44; e s&#227;o expressas em mil&#237;metros&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A localiza&#231;&#227;o do tumor foi estratificada pelo risco de recorr&#234;ncia de acordo com a classifica&#231;&#227;o da National Comprehensive Cancer Network &#40;NCCN&#41; como de alto&#44; moderado e baixo risco&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> Em seguida&#44; quatro grandes &#225;reas de alto risco foram analisadas e comparadas &#40;isto &#233;&#44; periocular&#44; nariz&#44; perioral&#44; orelha&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Os CBCs foram classificados&#44; de acordo com os subtipos histopatol&#243;gicos&#44; em baixo risco &#40;superficial&#44; nodular&#44; trabecular e &#8220;misto de baixo risco&#8221;&#41; e alto risco &#40;micronodular&#44; infiltrativo&#44; esclerodermiforme&#44; metat&#237;pico e &#8220;misto de alto risco&#8221;&#41;&#46; Quando mais de um subtipo estava presente&#44; o CBC foi classificado com base no subtipo mais agressivo&#44; em um dos dois grupos&#58; &#8220;misto de alto risco&#8221; &#40;quando pelo menos um subtipo agressivo estava presente&#41; ou &#8220;misto de baixo risco&#8221; &#40;quando todos os subtipos eram de baixo risco&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Quando um tumor apresentou invas&#227;o perineural ou um subtipo histopatol&#243;gico de alto risco&#44; foi classificado como tendo uma histopatologia agressiva ou crit&#233;rios de alto risco&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Tanto a les&#227;o quanto o defeito cir&#250;rgico final ap&#243;s a CMM foram medidos&#44; com comprimento e largura relatados em mil&#237;metros&#46; Em seguida&#44; os di&#226;metros foram calculados como a m&#233;dia de comprimento e largura para defeito &#40;<span class="elsevierStyleItalic">D</span>&#41; e les&#227;o &#40;<span class="elsevierStyleItalic">d</span>&#41;&#46; A margem cir&#250;rgica final necess&#225;ria &#40;<span class="elsevierStyleItalic">m</span>&#41; foi calculada como a diferen&#231;a entre o di&#226;metro final do defeito &#40;<span class="elsevierStyleItalic">D</span>&#41; e o di&#226;metro da les&#227;o &#40;<span class="elsevierStyleItalic">d&#41; &#8211;</span><a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#46; As medidas foram realizadas por uma equipe fixa de cirurgi&#245;es com especializa&#231;&#227;o na cirurgia de Mohs e com experi&#234;ncia nessa &#225;rea&#44; utilizando o mesmo m&#233;todo&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">An&#225;lise estat&#237;stica</span><p id="par0050" class="elsevierStylePara elsevierViewall">Os dados foram analisados pelo software SPSS vers&#227;o 25 &#40;Armonk&#44; NY&#58; IBM Corp&#46;&#41; Ap&#243;s verificar a distribui&#231;&#227;o n&#227;o normal das vari&#225;veis&#44; foram realizados os testes de Mann&#8208;Whitney e Kruskal&#8208;Wallis para comparar o n&#250;mero de est&#225;gios da CMM e as margens finais com outras vari&#225;veis clinicopatol&#243;gicas&#44; seguido de an&#225;lise <span class="elsevierStyleItalic">post&#8208;hoc</span> para compara&#231;&#245;es m&#250;ltiplas&#46; A correla&#231;&#227;o de Spearman foi utilizada para correlacionar as vari&#225;veis quantitativas&#46; Um modelo de regress&#227;o linear foi utilizado para listar os preditores mais associados ao n&#250;mero de tempos de cirurgia&#46; Na estat&#237;stica descritiva&#44; os dados qualitativos s&#227;o apresentados como porcentagem &#40;&#37;&#41; e n&#250;mero &#40;n&#41;&#44; e os dados quantitativos com m&#233;dia e desvio padr&#227;o&#44; quando desej&#225;vel&#46; O n&#237;vel de signific&#226;ncia foi estabelecido em p &#8804; 0&#44;05&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Todos os pacientes assinaram um termo de consentimento livre e informado dando permiss&#227;o para o uso desses dados&#44; e a pesquisa foi conduzida de acordo com o Comit&#234; de &#201;tica local&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Caracteriza&#231;&#227;o da popula&#231;&#227;o e dos tumores</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">Foram inclu&#237;dos 116 CBCs&#44; em 113 pacientes &#40;60 mulheres e 53 homens&#41; com m&#233;dia de idade de 70 anos &#40;varia&#231;&#227;o de 31 a 92&#41;&#44; em uma popula&#231;&#227;o majoritariamente n&#227;o imunossuprimida &#40;87&#44;9&#37;&#41;&#46; Em m&#233;dia&#44; os CBCs mediam 14&#44;66<span class="elsevierStyleHsp" style=""></span>mm &#40;intervalo 4&#8208;58<span class="elsevierStyleHsp" style=""></span>mm&#41; e quase todos estavam localizados em &#225;reas de alto risco &#40;94&#44;8&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>110&#41;&#44; principalmente no nariz &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>77&#59; <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46; A maioria dos CBCs era de tumores prim&#225;rios &#40;63&#44;8&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>74&#41;&#44; 24&#44;1&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>28&#41; eram recorrentes e 12&#44;1&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#41; eram CBCs persistentes &#40;anteriormente submetidos a ex&#233;rese incompleta&#41;&#46; A maioria deles apresentava pelo menos um crit&#233;rio histopatol&#243;gico de alto risco &#40;74&#44;1&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>86&#41; relacionado a um subtipo histopatol&#243;gico agressivo em 73&#44;3&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>85&#41; ou invas&#227;o perineural em 3&#44;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Em rela&#231;&#227;o aos subtipos histopatol&#243;gicos de alto risco&#44; o mais comum foi o infiltrativo &#40;22&#44;4&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41;&#44; seguido pelo micronodular &#40;13&#44;8&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#41;&#44; metat&#237;pico &#40;5&#44;2&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41; e esclerodermiforme &#40;4&#44;3&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&#59; 32 casos &#40;27&#44;6&#37;&#41; eram mistos de alto risco &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Rela&#231;&#227;o entre vari&#225;veis clinicopatol&#243;gicas e n&#250;mero de est&#225;gios da CMM</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">A maioria dos CBCs &#40;61&#44;2&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>71&#41; necessitou de um &#250;nico est&#225;gio da cirurgia para remo&#231;&#227;o completa do tumor&#59; 31&#44;9&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>37&#41; precisaram de dois est&#225;gios&#44; 5&#44;2&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41; precisaram de tr&#234;s e apenas 0&#44;9&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; dos casos necessitou de quatro est&#225;gios&#44; com m&#233;dia de 1&#44;45 est&#225;gios &#40;&#177; 0&#44;64&#41;&#46; A <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a> resume a rela&#231;&#227;o das vari&#225;veis clinicopatol&#243;gicas com o n&#250;mero de est&#225;gios da CMM&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Embora os homens tenham exigido mais est&#225;gios do que as mulheres &#40;m&#233;dia de 1&#44;56 <span class="elsevierStyleItalic">versus</span> 1&#44;35&#41;&#44; isso n&#227;o foi estatisticamente significativo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;063&#41;&#46; A idade e o tamanho do tumor n&#227;o pareceram se correlacionar com o n&#250;mero de est&#225;gios necess&#225;rios &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8208;0&#44;035&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;707&#59; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;104&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;271&#41;&#46; Mesmo quando foram comparados tumores<span class="elsevierStyleHsp" style=""></span>&#62; 20<span class="elsevierStyleHsp" style=""></span>mm com aqueles &#8804; 20<span class="elsevierStyleHsp" style=""></span>mm&#44; n&#227;o foram encontradas diferen&#231;as estatisticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;263&#41;&#44; embora aqueles com d<span class="elsevierStyleHsp" style=""></span>&#62; 20<span class="elsevierStyleHsp" style=""></span>mm necessitassem de maior m&#233;dia de est&#225;gios cir&#250;rgicos &#40;1&#44;55 <span class="elsevierStyleItalic">versus</span> 1&#44;42&#41;&#46; Os imunossuprimidos apresentaram maior m&#233;dia de est&#225;gios da CMM &#40;1&#44;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;85&#41; do que os imunocompetentes &#40;1&#44;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;63&#41;&#44; embora isso n&#227;o fosse estatisticamente significativo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;838&#41;&#46; Tumores persistentes tiveram a maior m&#233;dia de est&#225;gios cir&#250;rgicos necess&#225;rios &#40;1&#44;86&#41;&#44; seguidos de tumores recorrentes &#40;1&#44;43&#41; e prim&#225;rios &#40;1&#44;38&#41;&#44; embora essas diferen&#231;as n&#227;o tenham signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;279&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Ao comparar as subunidades de alto risco&#44; ou seja&#44; &#225;rea periocular&#44; nariz&#44; &#225;rea perioral e orelha&#44; foi observada uma diferen&#231;a estatisticamente significativa no n&#250;mero de est&#225;gios da CMM necess&#225;rios para a ex&#233;rese completa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;025&#41;&#46; A <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a> mostra quais grupos espec&#237;ficos evidenciaram uma diferen&#231;a estatisticamente significativa&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Considerando os aspectos histopatol&#243;gicos&#44; ter uma histopatologia agressiva &#40;subtipo de alto risco ou invas&#227;o perineural&#41; influenciou de maneira significativa o n&#250;mero de est&#225;gios da CMM &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#41;&#46; Al&#233;m disso&#44; ao comparar os subtipos histopatol&#243;gicos de alto risco e baixo risco&#44; tamb&#233;m foi encontrada diferen&#231;a estatisticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#41;&#44; com subtipos de alto risco exigindo mais est&#225;gios cir&#250;rgicos &#40;m&#233;dia de 1&#44;55&#41; do que os subtipos de baixo risco &#40;m&#233;dia de 1&#44;19&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Ao realizar uma an&#225;lise multivariada com modelo de regress&#227;o linear&#44; concluiu&#8208;se que o n&#250;mero de est&#225;gios da CMM foi influenciado principalmente pela localiza&#231;&#227;o periocular do tumor &#40;p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e pelo subtipo histopatol&#243;gico de alto risco &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41;&#46; Ou seja&#44; em tumores perioculares&#44; o n&#250;mero de est&#225;gios da CMM aumenta em m&#233;dia 0&#44;89 vez&#46; Nos subtipos histopatol&#243;gicos de alto risco&#44; o n&#250;mero de est&#225;gios da CMM aumenta em m&#233;dia 0&#44;36 vez&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Correla&#231;&#227;o das vari&#225;veis clinicopatol&#243;gicas com as margens cir&#250;rgicas</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">O di&#226;metro m&#233;dio do defeito cir&#250;rgico final &#40;D&#41; foi de 20&#44;75<span class="elsevierStyleHsp" style=""></span>mm &#40;varia&#231;&#227;o 6&#44;5&#8211;60&#41;&#44; com m&#233;dia de 3&#44;11<span class="elsevierStyleHsp" style=""></span>mm para as margens cir&#250;rgicas finais necess&#225;rias &#40;m&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">N&#227;o foi encontrada uma rela&#231;&#227;o significante entre as caracter&#237;sticas cl&#237;nicas ou histopatol&#243;gicas estudadas e a varia&#231;&#227;o das margens cir&#250;rgicas finais &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Embora os homens necessitassem de margens maiores para a remo&#231;&#227;o completa do tumor do que as mulheres &#40;m&#233;dia de 3&#44;25 <span class="elsevierStyleItalic">versus</span> 2&#44;99<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; isso n&#227;o foi estatisticamente significativo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;985&#41;&#46; Nem a idade do paciente&#44; nem a dimens&#227;o do tumor se correlacionaram de maneira significativa com as margens cir&#250;rgicas finais &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;118&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;227&#59; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;029&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;766&#41;&#46; Tumores<span class="elsevierStyleHsp" style=""></span>&#62; 20<span class="elsevierStyleHsp" style=""></span>mm exigiram margens cir&#250;rgicas maiores &#40;m&#233;dia 4&#44;22<span class="elsevierStyleHsp" style=""></span>mm&#41; do que aqueles medindo &#8804; 20<span class="elsevierStyleHsp" style=""></span>mm &#40;m&#233;dia 2&#44;88<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; mas novamente sem signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;166&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Tumores persistentes apresentaram a maior m&#233;dia de margens cir&#250;rgicas necess&#225;rias para ex&#233;rese completa &#40;4&#44;27<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; seguidos de tumores recorrentes &#40;3&#44;71<span class="elsevierStyleHsp" style=""></span>mm&#41; e prim&#225;rios &#40;2&#44;68<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; embora essas diferen&#231;as n&#227;o tenham demonstrado signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;234&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Tumores na regi&#227;o periocular necessitaram das maiores margens &#40;m&#233;dia de 4&#44;55<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; seguidos de tumores na regi&#227;o perioral &#40;m&#233;dia de 2&#44;93<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; nariz &#40;m&#233;dia de 2&#44;80<span class="elsevierStyleHsp" style=""></span>mm&#41; e orelha &#40;m&#233;dia de 2&#44;36<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; embora as diferen&#231;as n&#227;o tenham sido estatisticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;811&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Margens cir&#250;rgicas maiores foram necess&#225;rias quando havia crit&#233;rios histopatol&#243;gicos de alto risco &#40;m&#233;dia 3&#44;23 <span class="elsevierStyleItalic">versus</span> 2&#44;72<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; mas isso n&#227;o foi estatisticamente significativo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;837&#41;&#46; Al&#233;m disso&#44; apesar de n&#227;o haver signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;936&#41;&#44; as margens aumentam com o aumento do n&#250;mero de crit&#233;rios histopatol&#243;gicos de alto risco&#44; com m&#233;dia de 2&#44;74<span class="elsevierStyleHsp" style=""></span>mm se n&#227;o houver fatores de risco histopatol&#243;gicos&#44; 3&#44;23<span class="elsevierStyleHsp" style=""></span>mm se houver e 3&#44;33<span class="elsevierStyleHsp" style=""></span>mm quando h&#225; dois fatores&#46; Comparando os subtipos histopatol&#243;gicos de alto e baixo risco&#44; houve diferen&#231;as &#40;subtipos de alto risco levaram a um aumento m&#233;dio de margem de 3&#44;23<span class="elsevierStyleHsp" style=""></span>mm&#44; enquanto os de baixo risco&#44; de 2&#44;74<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; mas n&#227;o foram estatisticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;933&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">4&#41; Aspectos cir&#250;rgicos</p><p id="par0150" class="elsevierStylePara elsevierViewall">A redu&#231;&#227;o do volume tumoral &#40;<span class="elsevierStyleItalic">debulking</span>&#41; foi realizada em quase todos os casos &#40;87&#44;1&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>101&#41;&#46; A maioria dos defeitos cir&#250;rgicos necessitou de retalho para reconstru&#231;&#227;o &#40;79&#44;3&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>92&#41;&#44; principalmente de avan&#231;o &#40;40&#44;5&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>47&#41;&#44; seguido de transposi&#231;&#227;o &#40;30&#44;2&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>35&#41; e rota&#231;&#227;o &#40;8&#44;6&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46; Em 12 pacientes &#40;10&#44;3&#37;&#41; foi poss&#237;vel o fechamento direto&#59; em sete &#40;6&#37;&#41; foi utilizado enxerto de pele de espessura total&#59; em um &#40;0&#44;9&#37;&#41; utilizou&#8208;se enxerto composto&#59; e quatro defeitos cir&#250;rgicos &#40;3&#44;4&#37;&#41; foram submetidos &#224; cicatriza&#231;&#227;o por segunda inten&#231;&#227;o&#46; Foi encontrada uma taxa de recorr&#234;ncia de 1&#44;7&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; com tempo m&#233;dio de seguimento de 13&#44;37 meses &#40;varia&#231;&#227;o 2&#8208;27&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discuss&#227;o</span><p id="par0155" class="elsevierStylePara elsevierViewall">O presente estudo teve como objetivo correlacionar as caracter&#237;sticas clinicopatol&#243;gicas pr&#233;&#8208;operat&#243;rias dos CBCs com o n&#250;mero de est&#225;gios da CMM &#40;desfecho prim&#225;rio&#41; e a extens&#227;o das margens cir&#250;rgicas p&#243;s&#8208;operat&#243;rias &#40;desfecho secund&#225;rio&#41; necess&#225;rios para a elimina&#231;&#227;o total do tumor&#46; Idealmente&#44; isso poderia ajudar a identificar quais tumores devem ser submetidos a um procedimento cir&#250;rgico mais cuidadoso e&#44; eventualmente&#44; maiores margens iniciais na CMM&#46; Em rela&#231;&#227;o ao n&#250;mero de est&#225;gios da CMM&#44; foi encontrada uma associa&#231;&#227;o significativa com subtipo histopatol&#243;gico de alto risco&#44; histopatologia agressiva e localiza&#231;&#227;o&#46; Entretanto&#44; em rela&#231;&#227;o &#224; margem lateral final&#44; foi encontrada apenas uma tend&#234;ncia para seu aumento com algumas vari&#225;veis&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">A maioria dos CBCs submetidos &#224; CMM no presente estudo mediam<span class="elsevierStyleHsp" style=""></span>&#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#44; estavam localizados principalmente em &#225;reas de alto risco ou apresentavam pelo menos um crit&#233;rio histopatol&#243;gico de alto risco&#44; o que est&#225; de acordo com as principais indica&#231;&#245;es para esse tipo de cirurgia&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Na maioria dos casos&#44; foi necess&#225;rio apenas um est&#225;gio da CMM&#46; Os homens necessitaram de mais est&#225;gios do que as mulheres&#44; aproximando&#8208;se da signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;063&#41;&#44; embora sem alcan&#231;&#225;&#8208;la&#46; Imunossupress&#227;o&#44; idade do paciente e tamanho do tumor n&#227;o influenciaram de maneira significativa o n&#250;mero de est&#225;gios da CMM na presente amostra&#46; Isso est&#225; em desacordo com outros estudos&#44; nos quais o tamanho pr&#233;&#8208;operat&#243;rio do tumor foi um preditor significativo de margens maiores e n&#250;mero de est&#225;gios&#44; especialmente quando<span class="elsevierStyleHsp" style=""></span>&#62; 20<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">7&#44;10&#44;11</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Embora sem signific&#226;ncia estat&#237;stica&#44; os tumores persistentes tiveram a maior m&#233;dia de est&#225;gios cir&#250;rgicos necess&#225;rios&#44; seguidos por tumores recorrentes e prim&#225;rios&#46; Outros estudos tamb&#233;m mostraram que tumores recorrentes precisam de mais est&#225;gios cir&#250;rgicos do que os prim&#225;rios&#44; mas n&#227;o avaliaram tumores persistentes&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Em rela&#231;&#227;o &#224; localiza&#231;&#227;o de alto risco&#44; h&#225; uma diferen&#231;a estatisticamente significativa em rela&#231;&#227;o ao n&#250;mero de est&#225;gios entre os tumores localizados na regi&#227;o periocular e aqueles localizados na orelha&#44; nariz ou &#225;rea perioral &#8211; os CBCs perioculares requerem mais est&#225;gios de cirurgia&#46; Embora a localiza&#231;&#227;o em &#225;reas de alto risco tenha se mostrado associada a maior n&#250;mero de est&#225;gios em estudos anteriores&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">4&#44;5&#44;7</span></a> a especifica&#231;&#227;o e a compara&#231;&#227;o entre v&#225;rias &#225;reas de alto risco s&#227;o mais raramente mencionadas na literatura&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Ter uma histopatologia agressiva &#40;seja subtipo de alto risco ou invas&#227;o perineural&#41; influenciou de maneira significativa o n&#250;mero de est&#225;gios da CMM&#44; e os subtipos de alto risco &#40;micronodular&#44; infiltrativo&#44; esclerodermiforme&#44; metat&#237;pico e &#8220;misto de alto risco&#8221;&#41; exigiram mais est&#225;gios cir&#250;rgicos do que os de baixo risco &#40;superficial&#44; nodular&#44; trabecular e &#8220;misto de baixo risco&#8221;&#41;&#44; o que est&#225; de acordo com outros estudos&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> Ao avaliar os subtipos histopatol&#243;gicos de baixo risco&#44; os CBCs superficiais apresentaram a maior m&#233;dia de est&#225;gios da CMM&#46; Isso est&#225; de acordo com um estudo recente de Cerci et al&#46;&#44; que mostrou que n&#227;o apenas os subtipos micronodular&#44; infiltrativo e esclerodermiforme&#44; mas tamb&#233;m o superficial&#44; estavam associados a margens maiores&#44; concluindo que os CBCs superficiais tinham maior extens&#227;o subcl&#237;nica&#44; levando a margens maiores e mais est&#225;gios cir&#250;rgicos&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Al&#233;m disso&#44; em 2013&#44; um grupo de dermatologistas e cirurgi&#245;es de cabe&#231;a e pesco&#231;o categorizou os CBCs superficiais como grupo histopatol&#243;gico de alto risco em virtude de seu padr&#227;o de crescimento irregular&#44; acarretando um maior risco de ex&#233;rese incompleta&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Tamb&#233;m foi avaliada a influ&#234;ncia dos mesmos fatores clinicopatol&#243;gicos nas margens cir&#250;rgicas necess&#225;rias para a remo&#231;&#227;o tumoral&#44; mas n&#227;o foi encontrada uma rela&#231;&#227;o estatisticamente significativa entre eles&#44; apenas algumas tend&#234;ncias&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Pode&#8208;se imaginar os tumores e defeitos cir&#250;rgicos como perfeitamente redondos&#44; mas na pr&#225;tica isso raramente acontece&#46; A configura&#231;&#227;o do defeito final costuma ser diferente da do tumor prim&#225;rio&#44; e os incrementos em comprimento e largura nem sempre s&#227;o harmoniosos ou sim&#233;tricos&#44; o que torna essa avalia&#231;&#227;o particularmente dif&#237;cil&#46; Al&#233;m disso&#44; deve&#8208;se levar em considera&#231;&#227;o que a t&#233;cnica utilizada para medir as margens de ex&#233;rese varia muito entre os autores&#44; e &#233; especialmente dif&#237;cil avali&#225;&#8208;la com precis&#227;o&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Apesar disso&#44; na literatura&#44; Cerci et al&#46; recentemente descobriram que CBCs medindo &#60;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm tinham uma taxa de elimina&#231;&#227;o de 96&#37; com margens &#8804; 3<span class="elsevierStyleHsp" style=""></span>mm&#46; Eles tamb&#233;m descobriram que os subtipos histopatol&#243;gicos superficial&#44; micronodular&#44; infiltrativo e esclerodermiforme estavam associados a margens maiores &#40;m&#233;dia de 3&#44;1&#44; 3&#44;9&#44; 2&#44;7 e 4<span class="elsevierStyleHsp" style=""></span>mm&#44; respectivamente&#41;&#44; enquanto tumores clinicamente bem definidos foram associados a margens menores &#40;m&#233;dia de 1&#44;9<span class="elsevierStyleHsp" style=""></span>mm <span class="elsevierStyleItalic">versus</span> 2&#44;9<span class="elsevierStyleHsp" style=""></span>mm para tumores mal definidos&#41;&#46; Curiosamente&#44; entretanto&#44; a localiza&#231;&#227;o em &#225;reas de alto risco n&#227;o foi associada de maneira significante a margens maiores&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Em outro estudo recente com 306 CBCs pequenos e agressivos na face &#40;definidos como tumores com &#60;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm na &#225;rea H e &#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mm na &#225;rea M&#41;&#44; as margens necess&#225;rias para a elimina&#231;&#227;o do tumor tamb&#233;m foram avaliadas&#46; Eles tamb&#233;m descobriram que 94&#44;9&#37; dos tumores medindo &#60;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm foram eliminados com margens de 3<span class="elsevierStyleHsp" style=""></span>mm e que uma margem de ressec&#231;&#227;o de 4<span class="elsevierStyleHsp" style=""></span>mm foi suficiente para realizar a ex&#233;rese completa da les&#227;o em 99&#37; dos casos de pequenos CBCs faciais prim&#225;rios com subtipos histopatol&#243;gicos agressivos&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Em um estudo anterior de Schell et al&#46; incluindo 385 CBCs&#44; margens m&#233;dias de 2&#44;4<span class="elsevierStyleHsp" style=""></span>mm e 3&#44;7<span class="elsevierStyleHsp" style=""></span>mm foram encontradas para tumores de baixo e alto risco&#44; respectivamente&#44; com margens de 4&#44;75<span class="elsevierStyleHsp" style=""></span>mm e 8<span class="elsevierStyleHsp" style=""></span>mm atingindo 95&#37; de elimina&#231;&#227;o do tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Observou&#8208;se uma taxa de recidiva menor do que aquela relatada na literatura &#40;3&#44;1&#37;&#8208;4&#44;9&#37;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3&#44;12&#44;13</span></a> o que n&#227;o deve ser valorizado em raz&#227;o do curto tempo de seguimento dos pacientes do presente estudo no momento em que o artigo estava sendo escrito&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Import&#226;ncia do estudo e novidades</span><p id="par0215" class="elsevierStylePara elsevierViewall">A import&#226;ncia do presente estudo reside em sua relev&#226;ncia cl&#237;nica&#44; uma vez que correlacionar as caracter&#237;sticas clinicopatol&#243;gicas pr&#233;&#8208;operat&#243;rias com ambos os est&#225;gios da CMM e as margens cir&#250;rgicas p&#243;s&#8208;operat&#243;rias pode ajudar a prever quais tumores ir&#227;o necessitar de um procedimento cir&#250;rgico mais cuidadoso e&#44; de maneira ideal&#44; orientar as margens cir&#250;rgicas iniciais na CMM&#46; Isso poderia ajudar a evitar tempos cir&#250;rgicos prolongados&#44; reduzindo n&#227;o apenas a morbidade cir&#250;rgica&#44; mas tamb&#233;m o tempo e os custos&#46; A CMM &#233; uma t&#233;cnica cir&#250;rgica altamente especializada e muito &#250;til&#44; mas demorada<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> e que requer treinamento&#44; pessoal e equipamentos especializados&#44; o que acarreta custos aumentados quando s&#227;o necess&#225;rios tempos cir&#250;rgicos extras&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">No presente estudo&#44; os principais fatores relacionados ao maior n&#250;mero de est&#225;gios da CMM foram a localiza&#231;&#227;o periocular do tumor&#44; ter uma histopatologia agressiva e subtipos histopatol&#243;gicos de alto risco&#46; Al&#233;m disso&#44; na literatura h&#225; poucos estudos abordando as margens necess&#225;rias para a remo&#231;&#227;o completa do CBC utilizando a CMM&#46; Em rela&#231;&#227;o a esse aspecto&#44; entretanto&#44; n&#227;o foi encontrada nenhuma vari&#225;vel capaz de predizer esse aumento&#44; o que pode decorrer das limita&#231;&#245;es do estudo&#46; No presente estudo&#44; a localiza&#231;&#227;o em &#225;reas de alto risco foi associada a maior n&#250;mero de est&#225;gios&#44; o que confirma o que havia sido relatado anteriormente na literatura&#46; O que &#233; novo &#233; a diferen&#231;a estatisticamente significativa no n&#250;mero de est&#225;gios entre tumores localizados na regi&#227;o periocular e tumores localizados na orelha&#44; nariz ou &#225;rea perioral &#40;todos considerados &#225;reas de alto risco&#41;&#44; com CBCs perioculares exigindo mais est&#225;gios de cirurgia&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Al&#233;m disso&#44; at&#233; onde foi poss&#237;vel investigar na literatura&#44; a maioria dos estudos compara tumores prim&#225;rios e recorrentes&#44; mas n&#227;o avalia os persistentes &#40;tumores anteriormente submetidos a ex&#233;rese incompleta&#41;&#46; Na presente amostra&#44; os tumores persistentes apresentaram a maior m&#233;dia de est&#225;gios cir&#250;rgicos necess&#225;rios&#44; seguidos pelos tumores recorrentes e prim&#225;rios&#44; mas sem signific&#226;ncia estat&#237;stica&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Limita&#231;&#245;es do estudo</span><p id="par0230" class="elsevierStylePara elsevierViewall">As limita&#231;&#245;es do presente estudo incluem sua natureza de centro &#250;nico com um pequeno tamanho amostral&#44; o que limita o valor das conclus&#245;es&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Al&#233;m disso&#44; como explicado anteriormente&#44; o m&#233;todo utilizado para medir os tumores e defeitos cir&#250;rgicos n&#227;o &#233; preciso e difere de outros m&#233;todos utilizados na literatura &#40;p&#46; ex&#46;&#44; muitos autores utilizam o eixo principal da les&#227;o em vez da m&#233;dia de comprimento e largura&#41;&#46; Isso pode explicar&#44; pelo menos em parte&#44; as dificuldades encontradas em estabelecer rela&#231;&#245;es estatisticamente significativas em rela&#231;&#227;o &#224;s margens cir&#250;rgicas finais&#46; No futuro ser&#225; &#250;til encontrar um m&#233;todo mais preciso e universal para se obter essas medidas&#44; que devem&#44; de maneira ideal&#44; incluir a profundidade da les&#227;o&#44; dando&#8208;lhe uma vis&#227;o tridimensional &#40;3D&#41;&#44; mais pr&#243;xima da realidade&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclus&#227;o</span><p id="par0240" class="elsevierStylePara elsevierViewall">No presente estudo&#44; os principais fatores relacionados ao maior n&#250;mero de est&#225;gios da CMM foram a localiza&#231;&#227;o periocular do tumor e os subtipos histopatol&#243;gicos de alto risco &#40;micronodular&#44; infiltrativo&#44; esclerodermiforme&#44; metat&#237;pico e &#8220;misto de alto risco&#8221;&#41;&#46; Nenhum dos outros fatores estudados mostrou influenciar estatisticamente o n&#250;mero de est&#225;gios da CMM&#46; N&#227;o foi encontrada nenhuma vari&#225;vel capaz de predizer o aumento da margem final necess&#225;ria para a ex&#233;rese completa&#44; o que pode ser decorrente do tamanho relativamente pequeno da amostra do estudo ou da limita&#231;&#227;o t&#233;cnica da medida do incremento de margem&#46; Estudos prospectivos maiores seriam ben&#233;ficos para corroborar esses resultados&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Suporte financeiro</span><p id="par0245" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Contribui&#231;&#227;o dos autores</span><p id="par0250" class="elsevierStylePara elsevierViewall">Joana Calv&#227;o&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; revis&#227;o cr&#237;tica da literatura&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica do manuscrito&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; an&#225;lise estat&#237;stica&#59; concep&#231;&#227;o e planejamento do estudo&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Andr&#233; Pinho&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica do manuscrito&#59; an&#225;lise estat&#237;stica&#59; concep&#231;&#227;o e planejamento do estudo&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Ana Brinca&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">Ricardo Vieira&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflito de interesses</span><p id="par0270" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Agradecimentos</span><p id="par0275" class="elsevierStylePara elsevierViewall">Os autores agradecem &#224; Dra&#46; Margarida Marques por sua ajuda com a an&#225;lise estat&#237;stica&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Fundamentos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A cirurgia microgr&#225;fica de Mohs &#40;CMM&#41; &#233; comumente utilizada para tratar o carcinoma basocelular &#40;CBC&#41; de alto risco&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Correlacionar as caracter&#237;sticas clinicopatol&#243;gicas pr&#233;&#8208;operat&#243;rias com o n&#250;mero de est&#225;gios da CMM &#40;desfecho prim&#225;rio&#41; e margens cir&#250;rgicas &#40;desfecho secund&#225;rio&#41; necess&#225;rios para a ex&#233;rese completa do CBC&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Foram analisados retrospectivamente os CBCs tratados com CMM no per&#237;odo de dois anos&#46; As vari&#225;veis estudadas inclu&#237;ram sexo&#44; idade e estado imunol&#243;gico&#44; tamanho da les&#227;o&#44; localiza&#231;&#227;o&#44; se era tumor prim&#225;rio&#44; recorrente ou persistente&#44; caracter&#237;sticas histopatol&#243;gicas&#44; n&#250;mero de est&#225;gios cir&#250;rgicos e quantidade de tecido excisado&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Um total de 116 CBCs foram inclu&#237;dos&#46; A maioria &#40;61&#44;2&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>71&#41; necessitou de cirurgia em est&#225;gio &#250;nico para ex&#233;rese completa&#44; exigindo margem final de 3&#44;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;35<span class="elsevierStyleHsp" style=""></span>mm&#46; Foram encontradas diferen&#231;as estatisticamente significantes entre a localiza&#231;&#227;o em diferentes &#225;reas de alto risco &#40;periocular&#44; perioral&#44; nariz&#44; orelha&#41; e o n&#250;mero de est&#225;gios da CMM necess&#225;rios para a ex&#233;rese completa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;025&#41;&#44; com tumores perioculares exigindo a maior m&#233;dia de est&#225;gios &#40;2&#44;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;95&#41;&#46; A presen&#231;a de caracter&#237;sticas histopatol&#243;gicas indicativas de comportamento agressivo influenciou significantemente o n&#250;mero de est&#225;gios da CMM &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#41;&#46; N&#227;o foi encontrada rela&#231;&#227;o significante entre as caracter&#237;sticas clinicopatol&#243;gicas e varia&#231;&#227;o nas margens cir&#250;rgicas finais&#44; apenas algumas tend&#234;ncias &#40;pacientes do sexo masculino&#44; tumores persistentes&#44; perioculares e histopatologia de alto risco exigiram margens maiores&#41;&#46; Nem a idade do paciente&#44; nem a dimens&#227;o do tumor apresentaram correla&#231;&#227;o significante com o n&#250;mero de est&#225;gios da CMM e margens cir&#250;rgicas finais&#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">As limita&#231;&#245;es deste estudo incluem sua natureza de centro &#250;nico com pequeno tamanho de amostra&#44; o que limita o valor das conclus&#245;es&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Os principais fatores relacionados ao maior n&#250;mero de est&#225;gios da CMM foram a localiza&#231;&#227;o periocular e o subtipo histopatol&#243;gico de alto risco do tumor&#46;</p></span>"
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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
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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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;969&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>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 &#40;&#177; 0&#44;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;00 &#40;&#177; 2&#44;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;46 &#40;&#177; 0&#44;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;14 &#40;&#177; 2&#44;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tumor prim&#225;rio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;38 &#40;&#177; 0&#44;51&#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  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;279</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;68 &#40;&#177; 1&#44;56&#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  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;234</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>Tumor recorrente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;43 &#40;&#177; 0&#44;63&#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">3&#44;71 &#40;&#177; 3&#44;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tumor persistente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;86 &#40;&#177; 1&#44;03&#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">4&#44;27 &#40;&#177; 3&#44;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Localiza&#231;&#227;o&#47;subunidade</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;025<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a></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  " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;811</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>Periocular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;29 &#40;&#177; 0&#44;95&#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">4&#44;55 &#40;&#177; 3&#44;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nariz&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;42 &#40;&#177; 0&#44;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;80 &#40;&#177; 1&#44;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Perioral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;36 &#40;&#177; 0&#44;67&#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&#44;93 &#40;&#177; 2&#44;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Orelha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;25 &#40;&#177; 0&#44;46&#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&#44;36 &#40;&#177; 1&#44;07&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Histopatologia agressiva</span><span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;012</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a></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  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;837</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>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;54 &#40;&#177; 0&#44;68&#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">3&#44;23 &#40;&#177; 2&#44;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;20 &#40;&#177; 0&#44;41&#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&#44;72 &#40;&#177; 1&#44;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Subtipo histopatol&#243;gico</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="12" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;008</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a></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  " rowspan="12" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;933</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alto risco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;55 &#40;</span>&#177; <span class="elsevierStyleBold">0&#44;68&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">3&#44;23 &#40;</span>&#177; <span class="elsevierStyleBold">2&#44;62&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;44 &#40;&#177; 0&#44;63&#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&#44;87 &#40;&#177; 1&#44;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;60 &#40;&#177; 0&#44;71&#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">3&#44;75 &#40;&#177; 2&#44;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ESC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;40 &#40;&#177; 0&#44;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MAR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Baixo risco&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"><span class="elsevierStyleBold">1&#44;19 &#40;</span>&#177; <span class="elsevierStyleBold">0&#44;40&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2&#44;74 &#40;</span>&#177; <span class="elsevierStyleBold">1&#44;29&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&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&#44;50 &#40;&#177; 0&#44;71&#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&#44;88 &#40;&#177; 0&#44;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;31 &#40;&#177; 0&#44;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;84 &#40;&#177; 1&#44;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;25 &#40;&#177; 0&#44;50&#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&#44;50 &#40;&#177; 0&#44;87&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MBR&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&#44;00 &#40;&#177; 0&#44;00&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Rela&#231;&#227;o das vari&#225;veis clinicopatol&#243;gicas com o n&#250;mero de est&#225;gios da cirurgia microgr&#225;fica de Mohs &#40;CMM&#41; e margens cir&#250;rgicas necess&#225;rias para a ex&#233;rese total do tumor</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">O n&#237;vel de signific&#226;ncia &#233; 0&#44;05 &#40;valor em <span class="elsevierStyleBold">negrito</span><span class="elsevierStyleSup"><span class="elsevierStyleBold">a</span></span>&#41;&#46; Os valores de signific&#226;ncia foram ajustados pela corre&#231;&#227;o de Bonferroni para m&#250;ltiplos testes&#46;</p>"
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&#8208;valor&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"><span class="elsevierStyleBold">2&#44;29 &#40;&#177; 0&#44;95&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Periocular &#42; orelha&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;29 &#42; 1&#44;25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;048</span><span class="elsevierStyleSup"><span class="elsevierStyleBold">a</span></span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Periocular &#42; nariz&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\ttop\n
                  \t\t\t\t">2&#44;29 &#42; 1&#44;42&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"><span class="elsevierStyleBold">0&#44;027</span><span class="elsevierStyleSup"><span class="elsevierStyleBold">a</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Periocular &#42; perioral&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;29 &#42; 1&#44;36&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"><span class="elsevierStyleBold">0&#44;054</span><span class="elsevierStyleSup"><span class="elsevierStyleBold">a</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Nariz</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;42 &#40;&#177; 0&#44;59&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&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"><span class="elsevierStyleHsp" style=""></span>Nariz &#42; orelha&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&#44;42 &#42; 1&#44;25&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&#44;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nariz &#42; perioral&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&#44;42 &#42; 1&#44;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;000&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="elsevierStyleBold">Perioral</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;36 &#40;&#177; 0&#44;67&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \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>Perioral &#42; orelha&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;36 &#42; 1&#44;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;000&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  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;25 &#40;&#177; 0&#44;46&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Influ&#234;ncia da localiza&#231;&#227;o dos CBCs no n&#250;mero de est&#225;gios necess&#225;rios da CMM&#44; comparando diferentes subunidades de alto risco &#40;&#225;rea periocular&#44; nariz&#44; &#225;rea perioral e orelha&#41;</p>"
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        0 => array:2 [
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                    0 => array:2 [
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ISSN: 26662752
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