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a espessura&#44; ou &#237;ndice de Breslow&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">2&#44;3</span></a> O sistema atual do American Joint Committee on Cancer &#40;AJCC&#41; utiliza o &#237;ndice de Breslow para o estadiamento&#44; selecionando o ponto de corte de 1<span class="elsevierStyleHsp" style=""></span>mm de espessura para a defini&#231;&#227;o de melanoma fino&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">4</span></a> O progn&#243;stico est&#225; diretamente relacionado ao diagn&#243;stico precoce&#44; uma vez que pacientes com melanomas finos apresentam sobrevida de 93&#37; em 10 anos&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">4&#44;5</span></a> Por outro lado&#44; a sobrevida &#233; inversamente proporcional &#224; espessura do tumor&#59; pacientes com melanomas com &#237;ndice de Breslow &#62; 4<span class="elsevierStyleHsp" style=""></span>mm apresentam sobrevida em 10 anos de apenas 39&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">O melanoma &#233; classificado em quatro subtipos principais&#44; que se diferenciam quanto &#224; epidemiologia&#44; apresenta&#231;&#227;o cl&#237;nica&#44; dermatoscopia&#44; histopatologia&#44; aspectos moleculares e evolu&#231;&#227;o&#44; e por isso devem ser estudados separadamente&#46; O melanoma extensivo superficial &#40;MES&#41; &#233; o subtipo mais comum em indiv&#237;duos de pele clara&#44; correspondendo a 70&#37; dos casos&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">2</span></a> Apresenta uma fase de crescimento radial&#44; definida por crescimento limitado &#224; epiderme ou focalmente na derme papilar&#44; seguida por uma fase de crescimento vertical com presen&#231;a de invas&#227;o&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A dermatoscopia &#233; um m&#233;todo proped&#234;utico n&#227;o invasivo que aumenta a acur&#225;cia do diagn&#243;stico do melanoma em 20&#37; a 30&#37; quando realizada por examinadores treinados&#59; aconselha&#8208;se seu uso rotineiro pelo dermatologista na avalia&#231;&#227;o de les&#245;es melanoc&#237;ticas&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">6&#8211;8</span></a> O acompanhamento em centros especializados em dermatoscopia leva ao diagn&#243;stico de melanomas com espessura menor&#44; al&#233;m de reduzir o n&#250;mero de bi&#243;psias desnecess&#225;rias&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">7&#44;9&#8211;11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Quanto mais fino &#233; o melanoma&#44; maior a dificuldade na avalia&#231;&#227;o dermatosc&#243;pica&#44; em decorr&#234;ncia do menor desarranjo estrutural presente nas les&#245;es iniciais&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">12&#8211;14</span></a> Diversos trabalhos t&#234;m sido conduzidos a fim de identificar crit&#233;rios dermatosc&#243;picos associados &#224; espessura do tumor&#44; com o intuito de obter uma estimativa pr&#233;&#8208;operat&#243;ria do &#237;ndice de Breslow&#44; bem como auxiliar no diagn&#243;stico precoce do melanoma&#44; mas os resultados s&#227;o vari&#225;veis e nenhum desses crit&#233;rios mostrou&#8208;se confi&#225;vel para estabelecer a abordagem cir&#250;rgica&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">15&#8211;18</span></a> Em raz&#227;o da import&#226;ncia do diagn&#243;stico precoce do melanoma&#44; foram analisadas&#44; neste estudo&#44; imagens dermatosc&#243;picas desses tumores com o objetivo de descrever e analisar aspectos cl&#237;nicos e dermatosc&#243;picos do MES&#44; correlacionando&#8208;os com a espessura do tumor&#44; agrupando os tumores em <span class="elsevierStyleItalic">in situ</span>&#44; invasivos com &#237;ndice de Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm e invasivos com &#237;ndice de Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Trata&#8208;se de um estudo transversal&#44; em que foram selecionados pacientes com melanomas diagnosticados no Ambulat&#243;rio de Les&#245;es Pigmentadas do Servi&#231;o de Dermatologia do Hospital das Cl&#237;nicas da Universidade Federal de Minas Gerais &#40;HC&#8208;UFMG&#41; e em cl&#237;nica privada&#44; no per&#237;odo de sete anos&#44; com diagn&#243;stico de MES confirmado por histopatologia&#44; que apresentavam registro fotogr&#225;fico dermatosc&#243;pico do tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">19</span></a> Os dados foram coletados do banco de imagens e do banco de dados dos servi&#231;os&#44; al&#233;m de an&#225;lise de prontu&#225;rios m&#233;dicos&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">De acordo com a rotina dos servi&#231;os&#44; os pacientes foram examinados com dermatosc&#243;pios Heine 20&#174; ou DermLite DL3&#174; &#40;luz n&#227;o polarizada&#41; e gel como fluido de interface&#59; as fotografias cl&#237;nicas e dermatosc&#243;picas das les&#245;es suspeitas foram obtidas com c&#226;meras fotogr&#225;ficas digitais Canon Power Shot 3&#44;2&#174; ou Nikon&#160;1&#174; sob Termo de Consentimento Livre e Esclarecido &#40;TCLE&#41;&#46; As les&#245;es suspeitas de melanoma foram encaminhadas para excis&#227;o cir&#250;rgica&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">O diagn&#243;stico de MES foi baseado em exame anatomopatol&#243;gico realizado por dermatopatologistas experientes&#46; Em casos de d&#250;vida sobre o subtipo histol&#243;gico&#44; foi realizada revis&#227;o da l&#226;mina&#46; Os pacientes selecionados preencheram os seguintes crit&#233;rios de inclus&#227;o&#58; melanoma prim&#225;rio classificado histologicamente como MES e com registro fotogr&#225;fico dermatosc&#243;pico de qualidade satisfat&#243;ria&#46; Os crit&#233;rios de exclus&#227;o foram&#58; demais subtipos de melanoma&#44; melanomas recidivados e registro fotogr&#225;fico de qualidade insatisfat&#243;ria&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Os aspectos cl&#237;nicos avaliados foram&#58; tamanho do tumor &#40;&#60;&#160;6&#160;mm ou &#8805;&#160;6&#160;mm&#41; e localiza&#231;&#227;o &#40;face&#44; cervical&#44; tronco&#44; membros superiores ou membros inferiores&#41;&#46; O aspecto histopatol&#243;gico avaliado foi o &#237;ndice de Breslow&#59; os tumores foram classificados em MES invasivos com &#237;ndice de Breslow&#160;&#8804;&#160;1&#160;mm e MES invasivos com &#237;ndice de Breslow&#160;&#62;&#160;1&#160;mm&#44; al&#233;m de melanoma <span class="elsevierStyleItalic">in situ</span> &#40;MIS&#41;&#44; em que o &#237;ndice de Breslow n&#227;o &#233; aplicado&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A an&#225;lise das imagens foi realizada de forma cega&#44; sem o conhecimento do &#237;ndice de Breslow e demais vari&#225;veis&#44; por duas observadoras &#40;FVB e MLPF&#41; com experi&#234;ncia na &#225;rea de dermatoscopia que&#44; em conjunto&#44; concordaram quanto &#224; presen&#231;a ou aus&#234;ncia dos crit&#233;rios avaliados&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Os crit&#233;rios e padr&#245;es dermatosc&#243;picos registrados est&#227;o mostrados nas <a class="elsevierStyleCrossRefs" href="#tbl0005">tabelas 1 e 2</a>&#44; respectivamente&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">20&#8211;28</span></a> Como muitas imagens n&#227;o foram examinadas com dermatosc&#243;pio de luz polarizada&#44; as cris&#225;lidas n&#227;o foram inclu&#237;das no estudo&#44; j&#225; que s&#243; podem ser observadas com esse tipo de aparelho&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">22&#44;23</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">A an&#225;lise estat&#237;stica se fez&#44; durante a parte descritiva&#44; pelo c&#225;lculo de m&#233;dias e propor&#231;&#245;es de vari&#225;veis cont&#237;nuas e qualitativas&#44; respectivamente&#46; A an&#225;lise univariada para compara&#231;&#227;o entre os grupos foi feita pelo teste do qui&#8208;quadrado ou o teste exato de Fisher&#46; O <span class="elsevierStyleItalic">software</span> usado foi o Stata vers&#227;o 13&#46; A qualifica&#231;&#227;o da signific&#226;ncia estat&#237;stica foi feita usando o limite de valor de p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">O projeto foi aprovado pela C&#226;mara do Departamento de Cl&#237;nica M&#233;dica da Faculdade de Medicina da UFMG e pelo Comit&#234; de &#201;tica em Pesquisa da UFMG &#40;parecer n&#176; ETIC &#8211; 0005&#46;0&#46;203&#46;000&#8208;09&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="par0070" class="elsevierStylePara elsevierViewall">Foram selecionados 76 MES em 62 pacientes&#44; dos quais 18&#160;foram exclu&#237;dos por perda de qualidade das fotos&#46; Logo&#44; foram avaliados 58 MES em 52 pacientes&#58; 31&#160;eram provenientes do Ambulat&#243;rio de Les&#245;es Pigmentadas do HC&#8208;UFMG e 21&#160;da cl&#237;nica privada&#46; Foram avaliados 24 MIS&#44; 28 MES invasivos com Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm e seis MES invasivos com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Entre os 34 MES invasivos&#44; o &#237;ndice de Breslow m&#233;dio foi de&#160;0&#44;82 &#177; 1&#44;08&#46; No grupo MES invasivo com Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm&#44; a m&#233;dia foi de&#160;0&#44;50 &#177; 0&#44;22&#59; no grupo MES invasivo com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#44; a m&#233;dia foi de&#160;2&#44;35 &#177; 2&#44;02&#46; Os aspectos cl&#237;nicos est&#227;o apresentados na <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Houve uma perda de dados na vari&#225;vel tamanho da les&#227;o&#44; uma vez que o estudo foi retrospectivo e&#44; na maioria das vezes&#44; esse aspecto n&#227;o foi registrado nos prontu&#225;rios m&#233;dicos&#46; Em apenas 38 casos esse dado apresentou&#8208;se dispon&#237;vel&#44; e foi classificado em<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm &#40;5 &#91;13&#44;2&#37;&#93; &#8211; todos do grupo MIS&#41; ou &#8805; 6<span class="elsevierStyleHsp" style=""></span>mm &#40;33 &#91;86&#44;8&#37;&#93;&#41;&#46; Os MIS apresentaram tamanho significativamente menor que os MES invasivos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">O tronco foi a localiza&#231;&#227;o mais frequente&#44; comum a 62&#44;1&#37; dos tumores em geral&#44; sem diferen&#231;a entre os grupos&#44; enquanto 20&#44;7&#37; dos melanomas foram localizados nos membros inferiores&#44; 8&#44;6&#37; nos membros superiores&#44; 5&#44;2&#37; na regi&#227;o cervical e 3&#44;5&#37; na face &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a> apresenta a frequ&#234;ncia dos crit&#233;rios dermatosc&#243;picos e as compara&#231;&#245;es entre os grupos&#46; As caracter&#237;sticas dermatosc&#243;picas mais frequentemente encontradas foram&#58; assimetria &#40;84&#44;5&#37;&#41;&#44; tr&#234;s ou mais cores &#40;81&#44;0&#37;&#41; e rede at&#237;pica &#40;79&#44;3&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">A rede at&#237;pica foi encontrada em 17 &#40;70&#44;8&#37;&#41; MIS&#44; 26 &#40;92&#44;9&#37;&#41; MES invasivos com Breslow<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#60;</span><span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm e tr&#234;s &#40;50&#44;0&#37;&#41; MES invasivos com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#46; Sua presen&#231;a foi significativamente menor em MES invasivos com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm quando comparados a MES invasivos com Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;029&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">O v&#233;u azul&#8208;esbranqui&#231;ado foi menos comum no grupo MIS &#40;seis casos&#44;&#160;25&#44;0&#37;&#41;&#44; quando comparado aos grupos MES invasivos com Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm &#40;14&#160;casos&#44;&#160;50&#44;0&#37;&#41; e MES invasivos com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm &#40;tr&#234;s casos&#44;&#160;50&#44;0&#37;&#41;&#44; por&#233;m n&#227;o o suficiente para atingir signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;055&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A rede invertida foi mais frequente nos MES invasivos com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#44; nos quais os quatro casos representaram&#44; proporcionalmente&#44; 66&#44;7&#37; da amostra&#44; enquanto o grupo MIS apresentou dois casos &#40;8&#44;3&#37;&#41; e o grupo MES invasivos com Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm&#44; quatro casos &#40;14&#44;3&#37;&#41;&#46; O fato de essa caracter&#237;stica ser mais comum ao grupo &#62; 1<span class="elsevierStyleHsp" style=""></span>mm fez com que tanto a compara&#231;&#227;o geral entre os tr&#234;s grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;009&#41; quanto a compara&#231;&#227;o entre MES com Breslow &#8804; e &#62; 1<span class="elsevierStyleHsp" style=""></span>mm &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#41; fosse estatisticamente significativa&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">A presen&#231;a de tr&#234;s ou mais cores&#44; comum a 47 tumores &#40;81&#44;0&#37; do total&#41;&#44; foi proporcionalmente mais frequente no grupo MES invasivos com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#44; com 100&#37; &#40;seis casos&#41;&#44; e diminuiu para 89&#44;3&#37;&#160;&#40;25 casos&#41; no grupo &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm e 66&#44;7&#37; &#40;16 casos&#41; no grupo MIS&#46; A diferen&#231;a foi significativa na compara&#231;&#227;o entre MIS e MES invasivo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;019&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Assimetria&#44; pontos e gl&#243;bulos at&#237;picos&#44; estrias radiadas e&#47;ou pseud&#243;podes&#44; estruturas de regress&#227;o&#44; &#225;rea hipopigmentada&#44; borr&#245;es&#44; vasos at&#237;picos&#44; &#225;rea vermelho&#8208;leitoso&#44; ilha dermatosc&#243;pica e &#225;rea cinza&#8208;azulado reticular n&#227;o apresentaram diferen&#231;a significativa nas propor&#231;&#245;es encontradas entre os grupos&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0025">tabela 5</a> apresenta os padr&#245;es dermatosc&#243;picos e as compara&#231;&#245;es entre os grupos&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Padr&#227;o multicomponente &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">figs&#46; 1 e 2</a>&#41; foi observado em 30 &#40;51&#44;7&#37;&#41; tumores&#46; Foram oito casos &#40;34&#44;8&#37;&#41; no grupo MIS&#44; 19 &#40;67&#44;9&#37;&#41; e 3 &#40;50&#44;0&#37;&#41; casos nos grupos MES invasivos com Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm e &#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#44; respectivamente&#44; tendo sido significativamente mais comum em MES invasivos do que em MIS &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;026&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">O padr&#227;o inespec&#237;fico &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#44; comum a seis &#40;10&#44;3&#37;&#41; dos tumores&#44; foi mais frequente no grupo MIS &#40;cinco tumores &#8211; 20&#44;8&#37;&#41;&#44; quando comparado aos grupos MES invasivos com Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm &#40;um caso &#8211; 3&#44;6&#37;&#41; e &#62; 1<span class="elsevierStyleHsp" style=""></span>mm &#40;nenhum caso&#41;&#46; A diferen&#231;a encontrada foi estatisticamente significativa na compara&#231;&#227;o entre MIS e MES invasivos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;028&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Os padr&#245;es reticular&#44; globular&#44; homog&#234;neo e <span class="elsevierStyleItalic">starbust</span> n&#227;o apresentaram diferen&#231;as entre os grupos&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discuss&#227;o</span><p id="par0140" class="elsevierStylePara elsevierViewall">A incid&#234;ncia do melanoma tem aumentado de modo alarmante nas &#250;ltimas d&#233;cadas em todo o mundo &#8211; entretanto&#44; com tend&#234;ncia &#224; estabiliza&#231;&#227;o da taxa de mortalidade&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">29</span></a> De fato&#44; a literatura mundial reporta um aumento na incid&#234;ncia de melanomas finos&#44; refletindo diagn&#243;stico mais precoce&#44; provavelmente em decorr&#234;ncia da dermatoscopia&#46; Outra hip&#243;tese seria que a melhora no diagn&#243;stico do melanoma resulte na detec&#231;&#227;o de um subgrupo de melanomas finos e de crescimento lento&#44; chamados de &#8220;<span class="elsevierStyleItalic">slow&#8208;growing melanomas</span>&#8221;&#44; que poderiam progredir apenas eventualmente para melanomas espessos&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">30</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">A amostra de 58 melanomas foi obtida por conveni&#234;ncia&#44; uma vez que para ser inclu&#237;do no estudo o paciente precisava ter foto dermatosc&#243;pica pr&#233;&#8208;operat&#243;ria&#46; Isso levou a uma perda de casos&#44; pois les&#245;es clinicamente pouco expressivas podem n&#227;o ter sido fotografadas&#46; Por outro lado&#44; pacientes com les&#245;es clinicamente muito sugestivas de melanoma podem ter sido encaminhados para a dermatologia ap&#243;s a remo&#231;&#227;o do tumor&#44; levando a uma perda dos melanomas em est&#225;gios avan&#231;ados&#46; Por isso&#44; acreditamos que o grupo de MES invasivos com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm tenha contado com apenas seis casos&#44; levando a m&#233;dia de espessura dos MES invasivos a ser de apenas 0&#44;82<span class="elsevierStyleHsp" style=""></span>mm&#46; A amostra pode ser considerada expressiva quando comparada a estudos brasileiros&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">15&#44;31</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Os MIS apresentaram tamanho m&#233;dio menor que os melanomas invasivos&#44; com diferen&#231;a estatisticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#46; Esse achado &#233; esperado&#44; j&#225; que na maioria das vezes os tumores menores tendem a ser menos invasivos&#44; e est&#225; de acordo com a literatura&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">32</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">As caracter&#237;sticas dermatosc&#243;picas mais encontradas neste estudo foram assimetria&#44; tr&#234;s ou mais cores&#44; rede at&#237;pica e pontos e gl&#243;bulos at&#237;picos&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">A assimetria foi o crit&#233;rio mais comum &#40;84&#44;5&#37;&#41;&#44; com frequ&#234;ncia semelhante entre os grupos&#44; o que est&#225; de acordo com estudos anteriores&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">15&#44;18&#44;32</span></a> A assimetria &#233; um achado mais frequente no MES quando comparado a outros subtipos de melanoma&#44; e pode estar ausente nos tumores nodulares e amelan&#243;ticos&#44; n&#227;o inclu&#237;dos neste estudo&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">33&#44;34</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">A presen&#231;a de tr&#234;s ou mais cores foi significativamente mais comum no MES invasivo que no MIS &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;019&#41; &#8211; o que est&#225; de acordo com a literatura&#59; &#233; sugerido que o aumento do n&#250;mero de cores pode estar diretamente relacionado ao &#237;ndice de Breslow&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">15&#44;18&#44;35</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Na fase de crescimento radial do melanoma&#44; observa&#8208;se prolifera&#231;&#227;o de melan&#243;citos at&#237;picos isolados ou agrupados em ninhos ao longo da jun&#231;&#227;o dermoepid&#233;rmica e nas camadas suprabasais &#40;dissemina&#231;&#227;o pagetoide&#41;&#46; Essa prolifera&#231;&#227;o pode causar altera&#231;&#245;es na rede pigmentar&#44; que se torna at&#237;pica&#44; e &#233; uma caracter&#237;stica de melanomas do subtipo MES&#44; podendo estar presente tamb&#233;m em nevos at&#237;picos&#46; Altera&#231;&#245;es na rede pigmentar s&#227;o mais facilmente vis&#237;veis em melanomas em est&#225;gios iniciais &#40;MIS e MES invasivos com Breslow &#8804; 0&#44;75<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; uma vez que com a progress&#227;o da les&#227;o h&#225; perda das cristas epiteliais&#44; e a rede pode ser vista apenas focalmente&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">36&#8211;40</span></a> Neste estudo&#44; a rede at&#237;pica foi mais comum em MES invasivos com Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm quando comparados com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#44; com diferen&#231;a estatisticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;029&#41;&#59; entretanto&#44; n&#227;o houve diferen&#231;a entre os grupos MIS e MES invasivo&#46; Isso pode ser justificado pelo fato de que a grande maioria dos casos do grupo MES invasivo apresenta Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm&#44; com m&#233;dia de Breslow de apenas 0&#44;50<span class="elsevierStyleHsp" style=""></span>mm&#44; apresentando caracter&#237;sticas dermatosc&#243;picas de melanomas finos&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">As estrias radiadas e&#47;ou pseud&#243;podes tamb&#233;m s&#227;o mais encontradas em melanomas do subtipo MES&#44; e foi sugerido por Argenziano et al&#46; que sua presen&#231;a indicaria fase de crescimento radial do tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">38</span></a> Entretanto&#44; em estudos mais recentes essas estruturas foram descritas com maior frequ&#234;ncia nos melanomas invasivos&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">15&#44;18&#44;36</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">A fase de crescimento vertical &#233; marcada pela invas&#227;o do tumor&#59; v&#233;u azul&#8208;esbranqui&#231;ado e vasos at&#237;picos s&#227;o mais comumente encontrados&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">41</span></a> O v&#233;u foi encontrado em 50&#37; dos melanomas invasivos e em 25&#37; dos MIS&#44; por&#233;m n&#227;o o suficiente para atingir signific&#226;ncia estat&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;055&#41;&#44; tendo sido considerado um achado <span class="elsevierStyleItalic">borderline</span>&#46; O v&#233;u &#233; uma estrutura altamente espec&#237;fica para o diagn&#243;stico de melanoma&#44; com especificidade de at&#233; 97&#37;&#44; e &#233; mais encontrado em melanomas com maior espessura&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">27&#44;42&#8211;44</span></a> Acreditamos que esse crit&#233;rio poderia ter atingido signific&#226;ncia estat&#237;stica caso o tamanho da amostra fosse maior&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">&#193;rea&#47;gl&#243;bulos vermelho&#8208;leitosos e vasos at&#237;picos surgem em decorr&#234;ncia do polimorfismo vascular&#44; que aumenta proporcionalmente ao aumento da espessura&#44; e s&#227;o mais frequentes em melanomas intermedi&#225;rios e espessos &#40;&#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">44</span></a> Essas estruturas s&#227;o mais facilmente vis&#237;veis em melanomas hipo&#47;amelan&#243;ticos&#44; nos quais podem ser a &#250;nica pista para o diagn&#243;stico&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">44</span></a> Acreditamos que o padr&#227;o vascular at&#237;pico pode ter sido subestimado neste estudo&#44; uma vez que os vasos seriam mais bem visualizados com luz polarizada&#44; e a dermatoscopia de contato pode comprimi&#8208;los e prejudicar sua avalia&#231;&#227;o nas imagens&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">45</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">A rede invertida &#233; caracter&#237;stica&#44; mas n&#227;o exclusiva de melanomas&#44; podendo ser vista no nevo de Spitz&#44; nevo at&#237;pico ou dermatofibroma&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">24&#44;46</span></a> No presente estudo&#44; foi encontrada em 17&#44;2&#37; dos casos&#44; com maior frequ&#234;ncia no grupo MES com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#41;&#44; o que est&#225; de acordo com a literatura&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">47&#44;48</span></a> A rede invertida foi encontrada com maior frequ&#234;ncia em melanomas invasivos com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm&#44; surgindo em nevos&#44; de localiza&#231;&#227;o no tronco e em pacientes jovens&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">48</span></a> Sua extens&#227;o e distribui&#231;&#227;o tamb&#233;m foram avaliadas&#44; de modo que sua presen&#231;a em mais de 20&#37; da les&#227;o e com distribui&#231;&#227;o heterog&#234;nea foram mais comuns nos melanomas invasivos&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">48</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">A ilha dermatosc&#243;pica&#44; descrita por Borsari et al&#46;&#44; consiste em uma &#225;rea circunscrita com padr&#227;o dermatosc&#243;pico diferente do restante da les&#227;o e foi considerada caracter&#237;stica de melanomas finos surgindo de nevos&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">26</span></a> Neste estudo&#44; foi encontrada em apenas tr&#234;s casos &#40;5&#44;2&#37;&#41; &#8211; dois MIS e um MES invasivo com Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm &#8211;&#44; e n&#227;o foi suficiente para atingir diferen&#231;a estatisticamente significativa&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">O padr&#227;o multicomponente &#233; considerado o mais caracter&#237;stico e mais associado ao melanoma&#44; e &#233; mais comum em melanomas invasivos&#46; J&#225; o padr&#227;o inespec&#237;fico&#44; encontrado em 10&#44;3&#37; dos casos&#44; foi significativamente mais comum no MIS &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;028&#41;&#46; Esse achado&#44; pelo nosso conhecimento&#44; n&#227;o foi descrito anteriormente na literatura&#44; mas &#233; esperado&#44; uma vez que &#224; medida que a espessura do tumor aumenta&#44; s&#227;o encontrados mais crit&#233;rios dermatosc&#243;picos espec&#237;ficos de melanoma&#46; Pode&#8208;se inferir que s&#227;o necess&#225;rios mais estudos sobre os melanomas incaracter&#237;sticos &#40;<span class="elsevierStyleItalic">featureless melanomas</span>&#41;&#44; com o intuito de estabelecer melhor os crit&#233;rios para seu diagn&#243;stico&#46; A exist&#234;ncia de melanomas com padr&#227;o inespec&#237;fico refor&#231;a a import&#226;ncia da hist&#243;ria cl&#237;nica&#44; e deve&#8208;se considerar bi&#243;psia de toda les&#227;o pigmentada em que um diagn&#243;stico benigno n&#227;o puder ser feito&#44; principalmente no caso de uma les&#227;o de in&#237;cio recente e&#47;ou com modifica&#231;&#227;o e sintomas&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">A avalia&#231;&#227;o dermatosc&#243;pica tem import&#226;ncia fundamental no diagn&#243;stico precoce e na estimativa pr&#233;&#8208;operat&#243;ria do &#237;ndice de Breslow do melanoma&#46; S&#227;o necess&#225;rios outros estudos&#44; sobretudo na popula&#231;&#227;o brasileira&#44; com maior amostra e maior propor&#231;&#227;o de melanomas intermedi&#225;rios e espessos&#44; para confirma&#231;&#227;o dos achados&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclus&#227;o</span><p id="par0210" class="elsevierStylePara elsevierViewall">Os melanomas em est&#225;gios iniciais apresentaram com maior frequ&#234;ncia padr&#227;o inespec&#237;fico &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;028&#41; e rede at&#237;pica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;029&#41;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Os melanomas invasivos apresentaram com maior frequ&#234;ncia tamanho &#8805; 6<span class="elsevierStyleHsp" style=""></span>mm &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#44; padr&#227;o multicomponentes &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;026&#41; e tr&#234;s ou mais cores &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;019&#41;&#44; enquanto os melanomas intermedi&#225;rios e espessos apresentaram com maior frequ&#234;ncia rede invertida &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">V&#233;u azul&#8208;esbranqui&#231;ado foi mais comum em MES invasivos&#44; sem atingir signific&#226;ncia estat&#237;stica&#46; Assimetria&#44; pontos e gl&#243;bulos at&#237;picos&#44; estrias radiadas e&#47;ou pseud&#243;podes&#44; estruturas de regress&#227;o&#44; &#225;rea hipopigmentada&#44; borr&#245;es&#44; vasos at&#237;picos&#44; &#225;rea vermelho&#8208;leitoso&#44; ilha dermatosc&#243;pica&#44; &#225;rea cinza&#8208;azulado reticular e os padr&#245;es reticular&#44; globular&#44; <span class="elsevierStyleItalic">starbust</span> e homog&#234;neo n&#227;o apresentaram diferen&#231;a significativa nas propor&#231;&#245;es encontradas entre os grupos&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Suporte financeiro</span><p id="par0225" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Contribui&#231;&#227;o dos autores</span><p id="par0230" class="elsevierStylePara elsevierViewall">Fernanda Marques Trindade&#58; An&#225;lise estat&#237;stica&#59; concep&#231;&#227;o e planejamento do estudo&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Fl&#225;via Vasques Bittencourt&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#59; elabora&#231;&#227;o e reda&#231;&#227;o 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 da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Maria Luiza Pires de Freitas&#58; 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></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflito de interesses</span><p id="par0245" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Fundamentos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A dermatoscopia aumenta a sensibilidade do diagn&#243;stico do melanoma&#44; levando &#224; sua identifica&#231;&#227;o precoce e aumentando as chances de cura&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descrever as caracter&#237;sticas cl&#237;nicas e dermatosc&#243;picas de melanomas extensivos superficiais e detectar as diferen&#231;as entre melanomas <span class="elsevierStyleItalic">in situ</span> e invasivos&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudo transversal em que foram avaliadas imagens dermatosc&#243;picas de 58 melanomas agrupados de acordo com sua espessura&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Foram avaliados 24 melanomas <span class="elsevierStyleItalic">in situ</span>&#44; 28 invasivos com Breslow &#8804; 1<span class="elsevierStyleHsp" style=""></span>mm &#40;0&#44;50 &#177; 0&#44;22<span class="elsevierStyleHsp" style=""></span>mm&#41; e seis com Breslow &#62; 1<span class="elsevierStyleHsp" style=""></span>mm &#40;2&#44;35 &#177; 2&#44;02<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; Os melanomas <span class="elsevierStyleItalic">in situ</span> apresentaram tamanho menor que os invasivos&#46; Os crit&#233;rios dermatosc&#243;picos mais encontrados foram assimetria &#40;84&#44;5&#37;&#41;&#44; tr&#234;s ou mais cores &#40;81&#44;0&#37;&#41; e rede at&#237;pica &#40;79&#44;3&#37;&#41;&#46; Padr&#227;o inespec&#237;fico foi mais comum nos melanomas <span class="elsevierStyleItalic">in situ</span> &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;028&#41;&#59; rede at&#237;pica em melanomas invasivos com Breslow 1<span class="elsevierStyleHsp" style=""></span>mm apresentaram rede invertida &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#41;&#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">Amostra de conveni&#234;ncia&#44; uma vez que era necess&#225;ria foto pr&#233;&#8208;operat&#243;ria do tumor&#44; o que pode ter levado &#224; perda das les&#245;es clinicamente menos expressivas e tamb&#233;m daquelas muito sugestivas de melanoma&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#245;es</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Melanomas em est&#225;gios iniciais apresentaram&#44; com maior frequ&#234;ncia&#44; padr&#227;o inespec&#237;fico e rede at&#237;pica&#44; enquanto melanomas invasivos apresentaram padr&#227;o multicomponentes&#44; tr&#234;s ou mais cores e rede invertida&#46;</p></span>"
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figura 3"
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          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Melanoma extensivo superficial <span class="elsevierStyleItalic">in situ</span> localizado na regi&#227;o cervical&#44; em paciente com melanomas m&#250;ltiplos&#46; &#192; dermatoscopia&#44; observa&#8208;se assimetria e varia&#231;&#227;o de cores&#44; entretanto sem estruturas espec&#237;ficas&#44; caracterizando padr&#227;o inespec&#237;fico&#46;</p>"
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        "etiqueta" => "Tabela 1"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Crit&#233;rio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Defini&#231;&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assimetria de contorno&#44; cores e estruturas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desigualdade quando a les&#227;o &#233; dividida em 0&#44; 1 ou 2&#160;eixos perpendiculares&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rede pigmentar at&#237;pica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rede irregular com varia&#231;&#227;o de cor&#44; espessura e espa&#231;amento de linhas e orif&#237;cios&#44; distribu&#237;dos assimetricamente&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pontos e gl&#243;bulos at&#237;picos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Estruturas arredondadas ou ovais&#44; com varia&#231;&#227;o de cor&#44; tamanho e formato&#44; distribu&#237;das irregularmente na les&#227;o&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">20&#44;21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Estrias radiadas e&#47;ou pseud&#243;podes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Estruturas lineares ou proje&#231;&#245;es bulbosas encontradas na borda da les&#227;o&#44; que podem estar conectadas ao corpo do tumor ou a uma rede pigmentada&#44; com colora&#231;&#227;o de marrom a negra&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">20&#44;21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">V&#233;u azul&#8208;esbranqui&#231;ado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#193;rea irregular&#44; sem estruturas&#44; com colora&#231;&#227;o azul&#8208;esbranqui&#231;ado em &#8220;vidro fosco&#8221;&#44; que encobre parte da les&#227;o&#46; A pigmenta&#231;&#227;o n&#227;o pode ocupar toda a extens&#227;o da les&#227;o&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Estruturas de regress&#227;o &#40;&#225;rea branca cicatricial e&#47;ou <span class="elsevierStyleItalic">peppering</span>&#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">&#193;rea despigmentada cicatricial com colora&#231;&#227;o mais clara que a pele normal e&#47;ou gr&#226;nulos azuis&#8208;acinzentados&#44; descritos como padr&#227;o tipo pimenta&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#193;rea hipopigmentada sem estrutura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#193;rea hipopigmentada sem estrutura perif&#233;rica ocupando mais de&#160;10&#37; da les&#227;o&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Borr&#227;o &#40;<span class="elsevierStyleItalic">blotch</span>&#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">&#193;rea preta&#44; marrom ou cinza&#44; sem estruturas&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Regular&#58; um borr&#227;o no centro da les&#227;o&#44; circundado por rede pigmentada&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Irregular&#58; mais de um borr&#227;o&#44; ou um borr&#227;o com localiza&#231;&#227;o perif&#233;rica&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vasos at&#237;picos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vasos puntiformes&#44; lineares irregulares ou polimorfos&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rede invertida&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rede hipopigmentada na qual as &#225;reas claras formam as traves e as pigmentadas preenchem os orif&#237;cios&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">21&#8208;24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#193;rea vermelho&#8208;leitoso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gl&#243;bulo e&#47;ou &#225;rea maior de cor vermelho&#8208;leitoso borrada ou sem foco&#44; que corresponde a uma parte elevada da les&#227;o&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">25</span></a> Consiste em aspecto vascular&#44; sem vasos espec&#237;ficos distingu&#237;veis&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ilha dermatosc&#243;pica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#193;rea circunscrita com padr&#227;o uniforme que difere do resto da les&#227;o&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#193;rea cinza&#8208;azulado reticular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rede cinza&#8208;azulado grosseira&#44; com linhas espessas e orif&#237;cios grandes&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">27&#44;28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Presen&#231;a de m&#250;ltiplas cores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Presen&#231;a de tr&#234;s ou mais cores&#44; entre preto&#44; marrom&#8208;claro&#44; marrom&#8208;escuro&#44; azul&#44; vermelho&#44; branco e cinza&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "pt" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Defini&#231;&#227;o dos crit&#233;rios dermatosc&#243;picos analisados nos melanomas extensivos superficiais</p>"
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            "identificador" => "at2"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Padr&#245;es&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Defini&#231;&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Padr&#227;o multicomponentes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Presen&#231;a de tr&#234;s ou mais crit&#233;rios&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Padr&#227;o inespec&#237;fico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Les&#227;o pigmentada sem padr&#227;o espec&#237;fico&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Padr&#227;o reticular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rede pigmentada cobrindo a maior parte da les&#227;o&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Padr&#227;o globular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Numerosos gl&#243;bulos de tamanhos variados com tonalidade marrom e&#47;ou cinza&#8208;enegrecido&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Padr&#227;o <span class="elsevierStyleItalic">starbust</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">Estrias radiadas e&#47;ou pseud&#243;podes em disposi&#231;&#227;o radial na borda da les&#227;o&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Padr&#227;o homog&#234;neo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pigmenta&#231;&#227;o marrom&#44; azul ou preto&#8208;acinzentado difusa na aus&#234;ncia de outras estruturas locais&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2579696.png"
              ]
            ]
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        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Defini&#231;&#227;o dos padr&#245;es dermatosc&#243;picos analisados nos melanomas extensivos superficiais</p>"
        ]
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        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at3"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Aspectos cl&#237;nicos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col"><span class="elsevierStyleItalic">In situ</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&#8804; 1 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&#62; 1 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Compara&#231;&#245;es &#40;p&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Geral entre 3 grupos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">In situ</span><span class="elsevierStyleItalic">vs</span>&#46; invasivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#8804; 1<span class="elsevierStyleHsp" style=""></span>mm <span class="elsevierStyleItalic">vs</span>&#46; &#62; 1 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tamanho tumor &#40;n&#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">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#160;6&#160;mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;35&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;13&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;&#160;6&#160;mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;64&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;86&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Localiza&#231;&#227;o &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Face&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;33&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;568&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;083&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cervical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;4&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;7&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tronco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;66&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;57&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;66&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;62&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MMSS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 &#40;4&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;14&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;8&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MMII&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;25&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;21&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;20&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2579698.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Aspectos cl&#237;nicos dos melanomas extensivos superficiais</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Tabela 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Crit&#233;rios dermatosc&#243;picos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col"><span class="elsevierStyleItalic">In situ</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&#8804; 1 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&#62; 1 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Compara&#231;&#245;es &#40;p&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Geral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">In situ</span><span class="elsevierStyleItalic">vs</span>&#46; invasivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#8804; 1<span class="elsevierStyleHsp" style=""></span>mm <span class="elsevierStyleItalic">vs</span>&#46; &#62; 1 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assimetria &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">3 &#40;12&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;17&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;16&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;15&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;877&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;722&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">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">21 &#40;87&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;82&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;83&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49 &#40;84&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rede at&#237;pica &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;29&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Pontos&#47;gl&#243;bulos at&#237;picos &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;653&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">Sim&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">15 &#40;58&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18 &#40;64&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;50&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">36 &#40;60&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Estrias&#47; pseud&#243;podes &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">39 &#40;67&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;16&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">V&#233;u &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Estruturas de regress&#227;o &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Borr&#245;es &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Vasos at&#237;picos &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Rede invertida &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#193;rea vermelho&#8208;leitoso &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#193;rea cinza&#8208;azulado reticular &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Tr&#234;s ou <span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span> cores &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;10&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;19&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;078&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">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">16 &#40;66&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;89&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47 &#40;81&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2579694.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Crit&#233;rios dermatosc&#243;picos identificados em melanomas extensivos superficiais</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Tabela 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Padr&#245;es dermatosc&#243;picos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col"><span class="elsevierStyleItalic">In situ</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&#8804; 1 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&#62; 1 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Compara&#231;&#245;es &#40;p&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Geral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">In situ</span><span class="elsevierStyleItalic">vs</span>&#46; invasivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#8804; 1<span class="elsevierStyleHsp" style=""></span>mm <span class="elsevierStyleItalic">vs</span>&#46; &#62; 1 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multicomponentes &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">16 &#40;66&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;32&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;50&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;48&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;062&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;026&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;641&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">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">8 &#40;33&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;67&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;50&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;51&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inespec&#237;fico &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">19 &#40;79&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;96&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52 &#40;89&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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;028&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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
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                          "etal" => true
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                            0 => "C&#46;K&#46; Bichakjian"
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Vol. 96. Núm. 2.
Páginas 139-147 (1 março 2021)
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17012
Vol. 96. Núm. 2.
Páginas 139-147 (1 março 2021)
Artigo original
Open Access
Estudo dermatoscópico do melanoma extensivo superficial
Visitas
17012
Fernanda Marques Trindadea,
Autor para correspondência
fmarquestrindade@gmail.com

Autor para correspondência.
, Maria Luiza Pires de Freitasb, Flávia Vasques Bittencourtb
a Serviço de Dermatologia, Hospital da Polícia Militar, Belo Horizonte, MG, Brasil
b Serviço de Dermatologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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Tabela 1. Definição dos critérios dermatoscópicos analisados nos melanomas extensivos superficiais
Tabela 2. Definição dos padrões dermatoscópicos analisados nos melanomas extensivos superficiais
Tabela 3. Aspectos clínicos dos melanomas extensivos superficiais
Tabela 4. Critérios dermatoscópicos identificados em melanomas extensivos superficiais
Tabela 5. Padrões dermatoscópicos identificados em melanomas extensivos superficiais
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Resumo
Fundamentos

A dermatoscopia aumenta a sensibilidade do diagnóstico do melanoma, levando à sua identificação precoce e aumentando as chances de cura.

Objetivo

Descrever as características clínicas e dermatoscópicas de melanomas extensivos superficiais e detectar as diferenças entre melanomas in situ e invasivos.

Métodos

Estudo transversal em que foram avaliadas imagens dermatoscópicas de 58 melanomas agrupados de acordo com sua espessura.

Resultados

Foram avaliados 24 melanomas in situ, 28 invasivos com Breslow ≤ 1mm (0,50 ± 0,22mm) e seis com Breslow > 1mm (2,35 ± 2,02mm). Os melanomas in situ apresentaram tamanho menor que os invasivos. Os critérios dermatoscópicos mais encontrados foram assimetria (84,5%), três ou mais cores (81,0%) e rede atípica (79,3%). Padrão inespecífico foi mais comum nos melanomas in situ (p=0,028); rede atípica em melanomas invasivos com Breslow 1mm apresentaram rede invertida (p=0,018).

Limitações do estudo

Amostra de conveniência, uma vez que era necessária foto pré‐operatória do tumor, o que pode ter levado à perda das lesões clinicamente menos expressivas e também daquelas muito sugestivas de melanoma.

Conclusões

Melanomas em estágios iniciais apresentaram, com maior frequência, padrão inespecífico e rede atípica, enquanto melanomas invasivos apresentaram padrão multicomponentes, três ou mais cores e rede invertida.

Palavras‐chave:
Dermoscopia
Melanoma
Neoplasias cutâneas
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Introdução

O melanoma representa apenas 5% dos tumores de pele, mas é responsável por cerca de 80% dos óbitos em decorrência de seu elevado potencial de metástase.1 Sua incidência vem crescendo em todo o mundo nas últimas décadas; no entanto, observa‐se uma tendência à estabilização da taxa de mortalidade,2 provavelmente pelo aumento no diagnóstico de melanomas iniciais.

O fator prognóstico mais importante do melanoma é a espessura, ou índice de Breslow.2,3 O sistema atual do American Joint Committee on Cancer (AJCC) utiliza o índice de Breslow para o estadiamento, selecionando o ponto de corte de 1mm de espessura para a definição de melanoma fino.4 O prognóstico está diretamente relacionado ao diagnóstico precoce, uma vez que pacientes com melanomas finos apresentam sobrevida de 93% em 10 anos.4,5 Por outro lado, a sobrevida é inversamente proporcional à espessura do tumor; pacientes com melanomas com índice de Breslow > 4mm apresentam sobrevida em 10 anos de apenas 39%.4

O melanoma é classificado em quatro subtipos principais, que se diferenciam quanto à epidemiologia, apresentação clínica, dermatoscopia, histopatologia, aspectos moleculares e evolução, e por isso devem ser estudados separadamente. O melanoma extensivo superficial (MES) é o subtipo mais comum em indivíduos de pele clara, correspondendo a 70% dos casos.2 Apresenta uma fase de crescimento radial, definida por crescimento limitado à epiderme ou focalmente na derme papilar, seguida por uma fase de crescimento vertical com presença de invasão.2

A dermatoscopia é um método propedêutico não invasivo que aumenta a acurácia do diagnóstico do melanoma em 20% a 30% quando realizada por examinadores treinados; aconselha‐se seu uso rotineiro pelo dermatologista na avaliação de lesões melanocíticas.6–8 O acompanhamento em centros especializados em dermatoscopia leva ao diagnóstico de melanomas com espessura menor, além de reduzir o número de biópsias desnecessárias.7,9–11

Quanto mais fino é o melanoma, maior a dificuldade na avaliação dermatoscópica, em decorrência do menor desarranjo estrutural presente nas lesões iniciais.12–14 Diversos trabalhos têm sido conduzidos a fim de identificar critérios dermatoscópicos associados à espessura do tumor, com o intuito de obter uma estimativa pré‐operatória do índice de Breslow, bem como auxiliar no diagnóstico precoce do melanoma, mas os resultados são variáveis e nenhum desses critérios mostrou‐se confiável para estabelecer a abordagem cirúrgica.15–18 Em razão da importância do diagnóstico precoce do melanoma, foram analisadas, neste estudo, imagens dermatoscópicas desses tumores com o objetivo de descrever e analisar aspectos clínicos e dermatoscópicos do MES, correlacionando‐os com a espessura do tumor, agrupando os tumores em in situ, invasivos com índice de Breslow ≤ 1mm e invasivos com índice de Breslow > 1mm.

Métodos

Trata‐se de um estudo transversal, em que foram selecionados pacientes com melanomas diagnosticados no Ambulatório de Lesões Pigmentadas do Serviço de Dermatologia do Hospital das Clínicas da Universidade Federal de Minas Gerais (HC‐UFMG) e em clínica privada, no período de sete anos, com diagnóstico de MES confirmado por histopatologia, que apresentavam registro fotográfico dermatoscópico do tumor.19 Os dados foram coletados do banco de imagens e do banco de dados dos serviços, além de análise de prontuários médicos.

De acordo com a rotina dos serviços, os pacientes foram examinados com dermatoscópios Heine 20® ou DermLite DL3® (luz não polarizada) e gel como fluido de interface; as fotografias clínicas e dermatoscópicas das lesões suspeitas foram obtidas com câmeras fotográficas digitais Canon Power Shot 3,2® ou Nikon 1® sob Termo de Consentimento Livre e Esclarecido (TCLE). As lesões suspeitas de melanoma foram encaminhadas para excisão cirúrgica.

O diagnóstico de MES foi baseado em exame anatomopatológico realizado por dermatopatologistas experientes. Em casos de dúvida sobre o subtipo histológico, foi realizada revisão da lâmina. Os pacientes selecionados preencheram os seguintes critérios de inclusão: melanoma primário classificado histologicamente como MES e com registro fotográfico dermatoscópico de qualidade satisfatória. Os critérios de exclusão foram: demais subtipos de melanoma, melanomas recidivados e registro fotográfico de qualidade insatisfatória.

Os aspectos clínicos avaliados foram: tamanho do tumor (< 6 mm ou ≥ 6 mm) e localização (face, cervical, tronco, membros superiores ou membros inferiores). O aspecto histopatológico avaliado foi o índice de Breslow; os tumores foram classificados em MES invasivos com índice de Breslow ≤ 1 mm e MES invasivos com índice de Breslow > 1 mm, além de melanoma in situ (MIS), em que o índice de Breslow não é aplicado.

A análise das imagens foi realizada de forma cega, sem o conhecimento do índice de Breslow e demais variáveis, por duas observadoras (FVB e MLPF) com experiência na área de dermatoscopia que, em conjunto, concordaram quanto à presença ou ausência dos critérios avaliados.

Os critérios e padrões dermatoscópicos registrados estão mostrados nas tabelas 1 e 2, respectivamente.20–28 Como muitas imagens não foram examinadas com dermatoscópio de luz polarizada, as crisálidas não foram incluídas no estudo, já que só podem ser observadas com esse tipo de aparelho.22,23

Tabela 1.

Definição dos critérios dermatoscópicos analisados nos melanomas extensivos superficiais

Critério  Definição 
Assimetria de contorno, cores e estruturas  Desigualdade quando a lesão é dividida em 0, 1 ou 2 eixos perpendiculares.20 
Rede pigmentar atípica  Rede irregular com variação de cor, espessura e espaçamento de linhas e orifícios, distribuídos assimetricamente.20 
Pontos e glóbulos atípicos  Estruturas arredondadas ou ovais, com variação de cor, tamanho e formato, distribuídas irregularmente na lesão.20,21 
Estrias radiadas e/ou pseudópodes  Estruturas lineares ou projeções bulbosas encontradas na borda da lesão, que podem estar conectadas ao corpo do tumor ou a uma rede pigmentada, com coloração de marrom a negra.20,21 
Véu azul‐esbranquiçado  Área irregular, sem estruturas, com coloração azul‐esbranquiçado em “vidro fosco”, que encobre parte da lesão. A pigmentação não pode ocupar toda a extensão da lesão.20 
Estruturas de regressão (área branca cicatricial e/ou pepperingÁrea despigmentada cicatricial com coloração mais clara que a pele normal e/ou grânulos azuis‐acinzentados, descritos como padrão tipo pimenta.20 
Área hipopigmentada sem estrutura  Área hipopigmentada sem estrutura periférica ocupando mais de 10% da lesão.20 
Borrão (blotchÁrea preta, marrom ou cinza, sem estruturas.20 
  Regular: um borrão no centro da lesão, circundado por rede pigmentada.21 
  Irregular: mais de um borrão, ou um borrão com localização periférica.21 
Vasos atípicos  Vasos puntiformes, lineares irregulares ou polimorfos.20 
Rede invertida  Rede hipopigmentada na qual as áreas claras formam as traves e as pigmentadas preenchem os orifícios.21‐24 
Área vermelho‐leitoso  Glóbulo e/ou área maior de cor vermelho‐leitoso borrada ou sem foco, que corresponde a uma parte elevada da lesão.25 Consiste em aspecto vascular, sem vasos específicos distinguíveis.21 
Ilha dermatoscópica  Área circunscrita com padrão uniforme que difere do resto da lesão.26 
Área cinza‐azulado reticular  Rede cinza‐azulado grosseira, com linhas espessas e orifícios grandes.27,28 
Presença de múltiplas cores  Presença de três ou mais cores, entre preto, marrom‐claro, marrom‐escuro, azul, vermelho, branco e cinza. 
Tabela 2.

Definição dos padrões dermatoscópicos analisados nos melanomas extensivos superficiais

Padrões  Definição 
Padrão multicomponentes  Presença de três ou mais critérios.20 
Padrão inespecífico  Lesão pigmentada sem padrão específico.20 
Padrão reticular  Rede pigmentada cobrindo a maior parte da lesão.20 
Padrão globular  Numerosos glóbulos de tamanhos variados com tonalidade marrom e/ou cinza‐enegrecido.20 
Padrão starbust  Estrias radiadas e/ou pseudópodes em disposição radial na borda da lesão.20 
Padrão homogêneo  Pigmentação marrom, azul ou preto‐acinzentado difusa na ausência de outras estruturas locais.20 

A análise estatística se fez, durante a parte descritiva, pelo cálculo de médias e proporções de variáveis contínuas e qualitativas, respectivamente. A análise univariada para comparação entre os grupos foi feita pelo teste do qui‐quadrado ou o teste exato de Fisher. O software usado foi o Stata versão 13. A qualificação da significância estatística foi feita usando o limite de valor de p=0,05.

O projeto foi aprovado pela Câmara do Departamento de Clínica Médica da Faculdade de Medicina da UFMG e pelo Comitê de Ética em Pesquisa da UFMG (parecer n° ETIC – 0005.0.203.000‐09).

Resultados

Foram selecionados 76 MES em 62 pacientes, dos quais 18 foram excluídos por perda de qualidade das fotos. Logo, foram avaliados 58 MES em 52 pacientes: 31 eram provenientes do Ambulatório de Lesões Pigmentadas do HC‐UFMG e 21 da clínica privada. Foram avaliados 24 MIS, 28 MES invasivos com Breslow ≤ 1mm e seis MES invasivos com Breslow > 1mm.

Entre os 34 MES invasivos, o índice de Breslow médio foi de 0,82 ± 1,08. No grupo MES invasivo com Breslow ≤ 1mm, a média foi de 0,50 ± 0,22; no grupo MES invasivo com Breslow > 1mm, a média foi de 2,35 ± 2,02. Os aspectos clínicos estão apresentados na tabela 3.

Tabela 3.

Aspectos clínicos dos melanomas extensivos superficiais

Aspectos clínicos  In situ  ≤ 1 mm  > 1 mm  Total  Comparações (p)
          Geral entre 3 grupos  In situvs. invasivo  ≤ 1mm vs. > 1 mm 
Tamanho tumor (n)  14  18  38       
< 6 mm  5 (35,7%)  0 (0%)  0 (0%)  5 (13,2%)  0,009  0,004  – 
≥ 6 mm  9 (64,3%)  18 (100%)  6 (100%)  33 (86,8%)       
Localização (n)  24  28  58       
Face  0 (0%)  0 (0%)  2 (33,3%)  2 (3,5%)  0,120  0,568  0,083 
Cervical  1 (4,2%)  2 (7,1%)  0 (0%)  3 (5,2%)       
Tronco  16 (66,7%)  16 (57,1%)  4 (66,7%)  36 (62,1%)       
MMSS  1 (4,2%)  4 (14,3%)  0 (0%)  5 (8,6%)       
MMII  6 (25,0%)  6 (21,4%)  0 (0%)  12 (20,7%)       

Houve uma perda de dados na variável tamanho da lesão, uma vez que o estudo foi retrospectivo e, na maioria das vezes, esse aspecto não foi registrado nos prontuários médicos. Em apenas 38 casos esse dado apresentou‐se disponível, e foi classificado em<6mm (5 [13,2%] – todos do grupo MIS) ou ≥ 6mm (33 [86,8%]). Os MIS apresentaram tamanho significativamente menor que os MES invasivos (p=0,004).

O tronco foi a localização mais frequente, comum a 62,1% dos tumores em geral, sem diferença entre os grupos, enquanto 20,7% dos melanomas foram localizados nos membros inferiores, 8,6% nos membros superiores, 5,2% na região cervical e 3,5% na face (tabela 3).

A tabela 4 apresenta a frequência dos critérios dermatoscópicos e as comparações entre os grupos. As características dermatoscópicas mais frequentemente encontradas foram: assimetria (84,5%), três ou mais cores (81,0%) e rede atípica (79,3%).

Tabela 4.

Critérios dermatoscópicos identificados em melanomas extensivos superficiais

Critérios dermatoscópicos  In situ  ≤ 1 mm  > 1 mm  Total  Comparações (p)
          Geral  In situvs. invasivo  ≤ 1mm vs. > 1 mm 
Assimetria (n)  24  28  58       
Não  3 (12,5%)  5 (17,9%)  1 (16,7%)  9 (15,5%)  0,877  0,722  1,000 
Sim  21 (87,5%)  23 (82,1%)  5 (83,3%)  49 (84,5%)       
Rede atípica (n)  24  28  58       
Não  7 (29,2%)  2 (7,1%)  3 (50,0%)  12 (20,7%)  0,020  0,181  0,029 
Sim  17 (70,8%)  26 (92,9%)  3 (50,0%)  46 (79,3%)       
Pontos/glóbulos atípicos (n)  24  28  58       
Não  10 (41,7%)  10 (35,7%)  3 (50,0%)  23 (39,7%)  0,783  0,792  0,653 
Sim  15 (58,3%)  18 (64,3%)  3 (50,0%)  36 (60,3%)       
Estrias/ pseudópodes (n)  24  28  58       
Não  16 (66,7%)  18 (64,3%)  5 (83,3%)  39 (67,2%)  0,548  0,938  0,638 
Sim  8 (33,3%)  10 (35,7%)  1 (16,7%)  19 (32,8%)       
Véu (n)  24  28  58       
Não  18 (75,0%)  14 (50,0%)  3 (50,0%)  35 (60,3%)  0,163  0,055  1,000 
Sim  6 (25,0%)  14 (50,0%)  3 (50,0%)  23 (39,7%)       
Estruturas de regressão (n)  24  28  58       
Não  20 (83,3%)  23 (82,1%)  5 (83,3%)  48 (82,8%)  0,993  0,922  1,000 
Sim  4 (16,7%)  5 (17,9%)  1 (16,7%)  10 (17,2%)       
Área hipopigmentada (n)  24  28  58       
Não  21 (87,5%)  24 (85,7%)  5 (83,3%)  50 (86,2%)  1,000  1,000  1,000 
Sim  3 (10,5%)  4 (14,3%)  1 (16,7%)  8 (13,8%)       
Borrões (n)  24  28  58       
Não  20 (83,3%)  24 (85,7%)  5 (83,3%)  49 (84,5%)  0,938  0,675  1,000 
Sim  4 (16,7%)  4 (14,3%)  1 (16,7%)  9 (15,5%)       
Vasos atípicos (n)  24  28  58       
Não  19 (79,2%)  21 (75,0%)  5 (83,3%)  45 (77,6%)  0,904  0,808  1,000 
Sim  5 (20,8%)  7 (25,0%)  1 (16,7%)  13 (22,4%)       
Rede invertida (n)  24  28  58       
Não  22 (91,7%)  24 (85,7%)  2 (33,3%)  48 (82,8%)  0,009  0,131  0,018 
Sim  2 (8,3%)  4 (14,3%)  4 (66,7%)  10 (17,2%)       
Área vermelho‐leitoso (n)  24  28  58       
Não  16 (66,7%)  16 (57,1%)  5 (83,3%)  37 (63,8%)  0,491  0,702  0,370 
Sim  8 (33,3%)  12 (42,9%)  1 (16,7%)  21 (36,2%)       
Ilha dermatoscópica (n)  24  28  58       
Não  22 (91,7%)  27 (96,4%)  6 (100%)  55 (94,8%)  0,706  0,564  1,000 
Sim  2 (8,3%)  1 (3,6%)  0 (0%)  3 (5,2%)       
Área cinza‐azulado reticular (n)  24  28  58       
Não  24 (100%)  25 (89,3%)  6 (100%)  55 (94,8%)  0,325  0,260  1.000 
Sim  0 (0%)  3 (10,7%)  0 (0%)  3 (5,2%)       
Três ou + cores (n)  24  28  58       
Não  8 (33,3%)  3 (10,7%)  0 (0%)  11 (19,0%)  0,078  0,019  1,000 
Sim  16 (66,7%)  25 (89,3%)  6 (100%)  47 (81,0%)       

A rede atípica foi encontrada em 17 (70,8%) MIS, 26 (92,9%) MES invasivos com Breslow<1mm e três (50,0%) MES invasivos com Breslow > 1mm. Sua presença foi significativamente menor em MES invasivos com Breslow > 1mm quando comparados a MES invasivos com Breslow ≤ 1mm (p=0,029).

O véu azul‐esbranquiçado foi menos comum no grupo MIS (seis casos, 25,0%), quando comparado aos grupos MES invasivos com Breslow ≤ 1mm (14 casos, 50,0%) e MES invasivos com Breslow > 1mm (três casos, 50,0%), porém não o suficiente para atingir significância estatística (p=0,055).

A rede invertida foi mais frequente nos MES invasivos com Breslow > 1mm, nos quais os quatro casos representaram, proporcionalmente, 66,7% da amostra, enquanto o grupo MIS apresentou dois casos (8,3%) e o grupo MES invasivos com Breslow ≤ 1mm, quatro casos (14,3%). O fato de essa característica ser mais comum ao grupo > 1mm fez com que tanto a comparação geral entre os três grupos (p=0,009) quanto a comparação entre MES com Breslow ≤ e > 1mm (p=0,018) fosse estatisticamente significativa.

A presença de três ou mais cores, comum a 47 tumores (81,0% do total), foi proporcionalmente mais frequente no grupo MES invasivos com Breslow > 1mm, com 100% (seis casos), e diminuiu para 89,3% (25 casos) no grupo ≤ 1mm e 66,7% (16 casos) no grupo MIS. A diferença foi significativa na comparação entre MIS e MES invasivo (p=0,019).

Assimetria, pontos e glóbulos atípicos, estrias radiadas e/ou pseudópodes, estruturas de regressão, área hipopigmentada, borrões, vasos atípicos, área vermelho‐leitoso, ilha dermatoscópica e área cinza‐azulado reticular não apresentaram diferença significativa nas proporções encontradas entre os grupos.

A tabela 5 apresenta os padrões dermatoscópicos e as comparações entre os grupos.

Tabela 5.

Padrões dermatoscópicos identificados em melanomas extensivos superficiais

Padrões dermatoscópicos  In situ  ≤ 1 mm  > 1 mm  Total  Comparações (p)
          Geral  In situvs. invasivo  ≤ 1mm vs. > 1 mm 
Multicomponentes (n)  24  28  58       
Não  16 (66,7%)  9 (32,1%)  3 (50,0%)  28 (48,3%)  0,062  0,026  0,641 
Sim  8 (33,3%)  19 (67,9%)  3 (50,0%)  30 (51,7%)       
Inespecífico (n)  24  28  58       
Não  19 (79,2%)  27 (96,4%)  6 (100%)  52 (89,7%)  0,136  0,028  1,000 
Sim  5 (20,8%)  1 (3,6%)  0 (0%)  6 (10,3%)       
Reticular (n)  24  28  58       
Não  19 (79,2%)  21 (75,0%)  5 (83,3%)  45 (77,6%)  0,904  0,808  1,000 
Sim  5 (20,8%)  7 (25,0%)  1 (16,7%)  13 (22,4%)       
Globular (n)  24  28  58       
Não  22 (91,7%)  27 (96,4%)  5 (83,3%)  54 (93,1%)  0,307  1,000  0,362 
Sim  2 (8,3%)  1 (3,6%)  1 (16,7%)  4 (6,9%)       
Starbust (n)  24  28  58       
Não  21 (87,5%)  28 (100%)  5 (83,3%)  54 (93,1%)  0,103  0,297  0,176 
Sim  3 (12,5%)  0 (0%)  1 (16,7%)  4 (6,9%)       
Homogêneo (n)  24  28  58       
Não  23 (95,8%)  28 (100%)  6 (100%)  57 (98,3%)  0,517  0,414  – 
Sim  1 (4,2%)  0 (0%)  0 (0%)  1 (1,7%)       

Padrão multicomponente (figs. 1 e 2) foi observado em 30 (51,7%) tumores. Foram oito casos (34,8%) no grupo MIS, 19 (67,9%) e 3 (50,0%) casos nos grupos MES invasivos com Breslow ≤ 1mm e > 1mm, respectivamente, tendo sido significativamente mais comum em MES invasivos do que em MIS (p=0,026).

Figura 1.

Melanoma extensivo superficial com Breslow 0,5mm; localizado na região cervical. À dermatoscopia, observa‐se assimetria de contorno, cores e estruturas, rede atípica, pontos e glóbulos atípicos, estrias radiadas e pseudópodes e véu azul‐esbranquiçado, caracterizando padrão multicomponentes.

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Figura 2.

Melanoma extensivo superficial com Breslow 0,6mm localizado na perna. À dermatoscopia, observa‐se assimetria, rede atípica, pontos e glóbulos atípicos, estruturas de regressão, vasos atípicos e área vermelho‐leitoso, caracterizando padrão multicomponentes.

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O padrão inespecífico (fig. 3), comum a seis (10,3%) dos tumores, foi mais frequente no grupo MIS (cinco tumores – 20,8%), quando comparado aos grupos MES invasivos com Breslow ≤ 1mm (um caso – 3,6%) e > 1mm (nenhum caso). A diferença encontrada foi estatisticamente significativa na comparação entre MIS e MES invasivos (p=0,028).

Figura 3.

Melanoma extensivo superficial in situ localizado na região cervical, em paciente com melanomas múltiplos. À dermatoscopia, observa‐se assimetria e variação de cores, entretanto sem estruturas específicas, caracterizando padrão inespecífico.

(0.16MB).

Os padrões reticular, globular, homogêneo e starbust não apresentaram diferenças entre os grupos.

Discussão

A incidência do melanoma tem aumentado de modo alarmante nas últimas décadas em todo o mundo – entretanto, com tendência à estabilização da taxa de mortalidade.29 De fato, a literatura mundial reporta um aumento na incidência de melanomas finos, refletindo diagnóstico mais precoce, provavelmente em decorrência da dermatoscopia. Outra hipótese seria que a melhora no diagnóstico do melanoma resulte na detecção de um subgrupo de melanomas finos e de crescimento lento, chamados de “slow‐growing melanomas”, que poderiam progredir apenas eventualmente para melanomas espessos.30

A amostra de 58 melanomas foi obtida por conveniência, uma vez que para ser incluído no estudo o paciente precisava ter foto dermatoscópica pré‐operatória. Isso levou a uma perda de casos, pois lesões clinicamente pouco expressivas podem não ter sido fotografadas. Por outro lado, pacientes com lesões clinicamente muito sugestivas de melanoma podem ter sido encaminhados para a dermatologia após a remoção do tumor, levando a uma perda dos melanomas em estágios avançados. Por isso, acreditamos que o grupo de MES invasivos com Breslow > 1mm tenha contado com apenas seis casos, levando a média de espessura dos MES invasivos a ser de apenas 0,82mm. A amostra pode ser considerada expressiva quando comparada a estudos brasileiros.15,31

Os MIS apresentaram tamanho médio menor que os melanomas invasivos, com diferença estatisticamente significativa (p=0,04). Esse achado é esperado, já que na maioria das vezes os tumores menores tendem a ser menos invasivos, e está de acordo com a literatura.32

As características dermatoscópicas mais encontradas neste estudo foram assimetria, três ou mais cores, rede atípica e pontos e glóbulos atípicos.

A assimetria foi o critério mais comum (84,5%), com frequência semelhante entre os grupos, o que está de acordo com estudos anteriores.15,18,32 A assimetria é um achado mais frequente no MES quando comparado a outros subtipos de melanoma, e pode estar ausente nos tumores nodulares e amelanóticos, não incluídos neste estudo.33,34

A presença de três ou mais cores foi significativamente mais comum no MES invasivo que no MIS (p=0,019) – o que está de acordo com a literatura; é sugerido que o aumento do número de cores pode estar diretamente relacionado ao índice de Breslow.15,18,35

Na fase de crescimento radial do melanoma, observa‐se proliferação de melanócitos atípicos isolados ou agrupados em ninhos ao longo da junção dermoepidérmica e nas camadas suprabasais (disseminação pagetoide). Essa proliferação pode causar alterações na rede pigmentar, que se torna atípica, e é uma característica de melanomas do subtipo MES, podendo estar presente também em nevos atípicos. Alterações na rede pigmentar são mais facilmente visíveis em melanomas em estágios iniciais (MIS e MES invasivos com Breslow ≤ 0,75mm), uma vez que com a progressão da lesão há perda das cristas epiteliais, e a rede pode ser vista apenas focalmente.36–40 Neste estudo, a rede atípica foi mais comum em MES invasivos com Breslow ≤ 1mm quando comparados com Breslow > 1mm, com diferença estatisticamente significativa (p=0,029); entretanto, não houve diferença entre os grupos MIS e MES invasivo. Isso pode ser justificado pelo fato de que a grande maioria dos casos do grupo MES invasivo apresenta Breslow ≤ 1mm, com média de Breslow de apenas 0,50mm, apresentando características dermatoscópicas de melanomas finos.

As estrias radiadas e/ou pseudópodes também são mais encontradas em melanomas do subtipo MES, e foi sugerido por Argenziano et al. que sua presença indicaria fase de crescimento radial do tumor.38 Entretanto, em estudos mais recentes essas estruturas foram descritas com maior frequência nos melanomas invasivos.15,18,36

A fase de crescimento vertical é marcada pela invasão do tumor; véu azul‐esbranquiçado e vasos atípicos são mais comumente encontrados.41 O véu foi encontrado em 50% dos melanomas invasivos e em 25% dos MIS, porém não o suficiente para atingir significância estatística (p=0,055), tendo sido considerado um achado borderline. O véu é uma estrutura altamente específica para o diagnóstico de melanoma, com especificidade de até 97%, e é mais encontrado em melanomas com maior espessura.27,42–44 Acreditamos que esse critério poderia ter atingido significância estatística caso o tamanho da amostra fosse maior.

Área/glóbulos vermelho‐leitosos e vasos atípicos surgem em decorrência do polimorfismo vascular, que aumenta proporcionalmente ao aumento da espessura, e são mais frequentes em melanomas intermediários e espessos (> 1mm).44 Essas estruturas são mais facilmente visíveis em melanomas hipo/amelanóticos, nos quais podem ser a única pista para o diagnóstico.44 Acreditamos que o padrão vascular atípico pode ter sido subestimado neste estudo, uma vez que os vasos seriam mais bem visualizados com luz polarizada, e a dermatoscopia de contato pode comprimi‐los e prejudicar sua avaliação nas imagens.45

A rede invertida é característica, mas não exclusiva de melanomas, podendo ser vista no nevo de Spitz, nevo atípico ou dermatofibroma.24,46 No presente estudo, foi encontrada em 17,2% dos casos, com maior frequência no grupo MES com Breslow > 1mm (p=0,018), o que está de acordo com a literatura.47,48 A rede invertida foi encontrada com maior frequência em melanomas invasivos com Breslow > 1mm, surgindo em nevos, de localização no tronco e em pacientes jovens.48 Sua extensão e distribuição também foram avaliadas, de modo que sua presença em mais de 20% da lesão e com distribuição heterogênea foram mais comuns nos melanomas invasivos.48

A ilha dermatoscópica, descrita por Borsari et al., consiste em uma área circunscrita com padrão dermatoscópico diferente do restante da lesão e foi considerada característica de melanomas finos surgindo de nevos.26 Neste estudo, foi encontrada em apenas três casos (5,2%) – dois MIS e um MES invasivo com Breslow ≤ 1mm –, e não foi suficiente para atingir diferença estatisticamente significativa.

O padrão multicomponente é considerado o mais característico e mais associado ao melanoma, e é mais comum em melanomas invasivos. Já o padrão inespecífico, encontrado em 10,3% dos casos, foi significativamente mais comum no MIS (p=0,028). Esse achado, pelo nosso conhecimento, não foi descrito anteriormente na literatura, mas é esperado, uma vez que à medida que a espessura do tumor aumenta, são encontrados mais critérios dermatoscópicos específicos de melanoma. Pode‐se inferir que são necessários mais estudos sobre os melanomas incaracterísticos (featureless melanomas), com o intuito de estabelecer melhor os critérios para seu diagnóstico. A existência de melanomas com padrão inespecífico reforça a importância da história clínica, e deve‐se considerar biópsia de toda lesão pigmentada em que um diagnóstico benigno não puder ser feito, principalmente no caso de uma lesão de início recente e/ou com modificação e sintomas.

A avaliação dermatoscópica tem importância fundamental no diagnóstico precoce e na estimativa pré‐operatória do índice de Breslow do melanoma. São necessários outros estudos, sobretudo na população brasileira, com maior amostra e maior proporção de melanomas intermediários e espessos, para confirmação dos achados.

Conclusão

Os melanomas em estágios iniciais apresentaram com maior frequência padrão inespecífico (p=0,028) e rede atípica (p=0,029).

Os melanomas invasivos apresentaram com maior frequência tamanho ≥ 6mm (p=0,04), padrão multicomponentes (p=0,026) e três ou mais cores (p=0,019), enquanto os melanomas intermediários e espessos apresentaram com maior frequência rede invertida (p=0,018).

Véu azul‐esbranquiçado foi mais comum em MES invasivos, sem atingir significância estatística. Assimetria, pontos e glóbulos atípicos, estrias radiadas e/ou pseudópodes, estruturas de regressão, área hipopigmentada, borrões, vasos atípicos, área vermelho‐leitoso, ilha dermatoscópica, área cinza‐azulado reticular e os padrões reticular, globular, starbust e homogêneo não apresentaram diferença significativa nas proporções encontradas entre os grupos.

Suporte financeiro

Nenhum.

Contribuição dos autores

Fernanda Marques Trindade: Análise estatística; concepção e planejamento do estudo; elaboração e redação do manuscrito; obtenção, análise e interpretação dos dados; revisão crítica da literatura; revisão crítica do manuscrito.

Flávia Vasques Bittencourt: Aprovação da versão final do manuscrito; concepção e planejamento do estudo; elaboração e redação do manuscrito; obtenção, análise e interpretação dos dados; participação efetiva na orientação da pesquisa; participação intelectual em conduta propedêutica e/ou terapêutica de casos estudados; revisão crítica da literatura; revisão crítica do manuscrito.

Maria Luiza Pires de Freitas: Obtenção, análise e interpretação dos dados; participação intelectual em conduta propedêutica e/ou terapêutica de casos estudados.

Conflito de interesses

Nenhum.

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Como citar este artigo: Trindade FM, Freitas MLP, Bittencourt FV. Dermoscopic evaluation of superficial spreading melanoma. An Bras Dermatol. 2021;96:139–47.

Trabalho realizado no Departamento de Dermatologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.

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