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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">El c&#225;ncer de pulm&#243;n &#40;CP&#41; supone un importante problema de salud&#58; es uno de los tipos de c&#225;ncer m&#225;s frecuentes y el que presenta una mayor mortalidad&#46; Su supervivencia global a los 5<span class="elsevierStyleHsp" style=""></span>a&#241;os no supera el 16&#37;&#44; pron&#243;stico que est&#225; directamente relacionado con el estadio de la enfermedad en el momento del diagn&#243;stico&#46; La prevenci&#243;n primaria del tabaquismo es clave para reducir su incidencia&#44; y el mayor n&#250;mero de casos se diagnostica entre exfumadores&#46; Aun con esta prevenci&#243;n primaria y los recientes avances en el tratamiento&#44; el diagn&#243;stico precoz de la enfermedad es la clave para reducir su mortalidad&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El <span class="elsevierStyleItalic">International Early Lung Cancer Action Program</span> &#40;I-ELCAP&#41;&#44; estudio no aleatorizado&#44; ya en 2006 publicaba que el 85&#37; de los c&#225;nceres diagnosticados se encontraban en estadio<span class="elsevierStyleHsp" style=""></span>I&#44; con una supervivencia estimada a los 10<span class="elsevierStyleHsp" style=""></span>a&#241;os del 88&#37;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> &#40;del 92&#37; si los CP en estadio<span class="elsevierStyleHsp" style=""></span>I se resecaban antes del primer mes desde el diagn&#243;stico&#41;&#46; El <span class="elsevierStyleItalic">National Lung Screening Trial</span> &#40;NLST&#41; es el primer estudio de cribado aleatorizado en personas de alto riesgo que mostr&#243; una reducci&#243;n de la mortalidad por CP&#58; del 20&#44;3&#37; en el grupo cribado con TC de baja dosis &#40;TCBD&#41; frente la radiograf&#237;a de t&#243;rax&#44; y del 6&#44;7&#37; en la mortalidad global<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a>&#46; Estos resultados motivaron que la <span class="elsevierStyleItalic">U&#46;S&#46; Preventive Services Task Force</span> &#40;USPSTF&#41; recomendara en 2014 el cribado en sujetos de alto riesgo con un grado de evidencia 2B<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a>&#46; La <span class="elsevierStyleItalic">European Society of Radiology</span> &#40;ESR&#41; y la <span class="elsevierStyleItalic">European Respiratory Society</span> &#40;ERS&#41; mostraron en 2015 su apoyo al cribado<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a>&#46; Recientemente&#44; la <span class="elsevierStyleItalic">International Association for the Study of Lung Cancer</span> &#40;IASLC&#41; ha recomendado la implementaci&#243;n del cribado bas&#225;ndose en los resultados del estudio NELSON <span class="elsevierStyleItalic">&#40;NEderlands-leuvens Longkanker Screenings ONderzoek&#41;</span> presentados en la <span class="elsevierStyleItalic">IASLC 19th World Conference of Lung Cancer</span> en Toronto&#46; Confirma que el cribado con TCBD reduce la mortalidad por CP el 26&#37; en varones y hasta el 61&#37; en mujeres&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En Espa&#241;a contamos con la amplia experiencia de la Cl&#237;nica Universitaria de Navarra<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a>&#44; que tambi&#233;n forma parte de I-ELCAP&#44; aportando importantes contribuciones al cribado&#58; uso de la tomograf&#237;a por emisi&#243;n de positrones &#40;PET&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a>&#44; valor del enfisema y la enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> y creaci&#243;n de modelos predictivos de riesgo<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Apoyando las reflexiones sobre la implementaci&#243;n del cribado que la Sociedad Espa&#241;ola de Neumolog&#237;a y Cirug&#237;a Tor&#225;cica&#44; junto con otras sociedades&#44; public&#243; en 2017<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a>&#44; pretendemos mostrar con nuestros datos que la TCBD integrada en un protocolo estructurado permite detectar CP en estadios tempranos potencialmente curables&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Poblaci&#243;n de estudio</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se incluyeron personas que entraron en el programa de cribado de CP de la Fundaci&#243;n IVO entre junio de 2008 y diciembre de 2012&#44; formando parte de una cohorte internacional en el programa I-ELCAP&#46; Cumpl&#237;an los siguientes criterios&#58; edad &#8805;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; fumadores o exfumadores con un h&#225;bito acumulado de&#44; al menos&#44; 10<span class="elsevierStyleHsp" style=""></span>paquetes-a&#241;o&#44; sin antecedentes personales de procesos oncol&#243;gicos &#40;excepto carcinomas basocelulares de piel&#41; y sin s&#237;ntomas sugestivos de CP&#46; Todos ellos fueron voluntarios &#40;algunos remitidos por su m&#233;dico de atenci&#243;n primaria&#44; la mayor&#237;a informados por otros participantes&#41; y&#44; tras ser informados del estudio y del riesgo de las t&#233;cnicas diagn&#243;sticas&#44; firmaron un documento de consentimiento aprobado por el comit&#233; de &#233;tica del hospital&#46; El seguimiento de los casos de CP diagnosticados finaliz&#243; el 31 de diciembre de 2016&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Algoritmo diagn&#243;stico</span><p id="par0030" class="elsevierStylePara elsevierViewall">Todas las exploraciones de TC se realizan con un TC helicoidal multidetector de 16 filas &#40;Siemens Emotion 16&#44; Erlangen&#44; Alemania&#41;&#46; Las im&#225;genes se adquirieron con par&#225;metros de baja dosis de radiaci&#243;n &#40;&#8804;<span class="elsevierStyleHsp" style=""></span>120<span class="elsevierStyleHsp" style=""></span>kVps y &#8804;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mAs&#41; con <span class="elsevierStyleItalic">CT Dose Index volumen</span> &#706;<span class="elsevierStyleHsp" style=""></span>2&#44;13<span class="elsevierStyleHsp" style=""></span>mGy y dep&#243;sito de energ&#237;a DLP <span class="elsevierStyleItalic">&#40;Dose Length Product&#41;</span> en el rango de 80-100<span class="elsevierStyleHsp" style=""></span>mGy&#42;cm&#46; El grosor de corte para par&#233;nquima pulmonar fue de 1<span class="elsevierStyleHsp" style=""></span>mm y para mediastino&#44; de 5<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A todos los participantes se les realiz&#243; un estudio basal y&#44; como m&#237;nimo&#44; otro estudio al a&#241;o&#46; Siguiendo el protocolo diagn&#243;stico de I-ELCAP &#40;<a href="http://www.ielcap.org/">www&#46;ielcap&#46;org</a>&#41; se identific&#243; y caracteriz&#243; los n&#243;dulos pulmonares hallados&#44; as&#237; como otros hallazgos en t&#243;rax-abdomen superior&#46; Se consider&#243; el estudio basal positivo ante n&#243;dulos no calcificados &#40;NNC&#41; s&#243;lidos o parcialmente s&#243;lidos de &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm o n&#243;dulos no s&#243;lidos &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mm&#46; En dicho caso se opt&#243; por control con TCBD en 3<span class="elsevierStyleHsp" style=""></span>meses&#44; PET-TC o biopsia seg&#250;n criterios de tama&#241;o o altamente sugestivos de malignidad&#46; Si hubo sospecha de infecci&#243;n&#44; se recomend&#243; un tratamiento antibi&#243;tico y control con TCBD al mes&#46; Si se evidenci&#243; una resoluci&#243;n parcial o completa&#44; el siguiente control se realiz&#243; al a&#241;o&#46; Los casos donde el estudio basal fue dado como negativo&#44; el siguiente control se realiz&#243; al a&#241;o&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">En el control anual se evalu&#243; la aparici&#243;n de nuevos n&#243;dulos&#44; el crecimiento de los existentes y todos los par&#225;metros del TCBD inicial&#46; Se consider&#243; positivo la aparici&#243;n de un n&#243;dulo s&#243;lido o parcialmente s&#243;lido de &#8805;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mm&#44; no s&#243;lido &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mm o un n&#243;dulo endobronquial s&#243;lido de &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm&#46; Se consideraron semipositivos los n&#243;dulos s&#243;lidos &#706;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mm o no s&#243;lidos &#706;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mm&#44; realizando un TCBD anual&#46; Ante n&#243;dulos s&#243;lidos entre 3 y 5<span class="elsevierStyleHsp" style=""></span>mm se realiz&#243; control TCBD en 6<span class="elsevierStyleHsp" style=""></span>meses&#46; En im&#225;genes sospechosas de un proceso infeccioso se recomend&#243; tratamiento antibi&#243;tico&#46; Si no se encontraron cambios ni nuevos n&#243;dulos&#44; se indic&#243; TCBD anual&#46; El crecimiento de un n&#243;dulo se defini&#243; como el aumento del mismo o de su componente s&#243;lido&#44; as&#237; como el tiempo de duplicaci&#243;n&#46; Si se precis&#243; biopsia&#44; se eligi&#243; la mejor t&#233;cnica seg&#250;n la localizaci&#243;n de la lesi&#243;n&#46; La m&#225;s empleada fue la punci&#243;n transtor&#225;cica guiada por TC&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">En los casos en que se lleg&#243; a un diagn&#243;stico de CP se complet&#243; el estudio de extensi&#243;n para estadificar la enfermedad&#44; conocer la resecabilidad del tumor y la operabilidad del paciente&#46; El tratamiento electivo se decidi&#243; de forma individual en consenso en el comit&#233; multidisciplinar de CP de nuestro hospital&#46; La clasificaci&#243;n TNM empleada en el presente trabajo corresponde a la octava edici&#243;n<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis estad&#237;stico</span><p id="par0050" class="elsevierStylePara elsevierViewall">Las diferentes variables demogr&#225;ficas&#44; radiol&#243;gicas&#44; caracter&#237;sticas de los CP diagnosticados&#44; etc&#46;&#44; se analizaron con el paquete estad&#237;stico para Windows<span class="elsevierStyleSup">&#174;</span> SPSS<span class="elsevierStyleSup">&#174;</span> versi&#243;n 22&#46; Se realiz&#243; un an&#225;lisis descriptivo y comparativo&#44; utilizando para este el m&#233;todo de chi-cuadrado &#40;&#967;<span class="elsevierStyleSup">2</span>&#41; o el test exacto de Fisher&#44; la t de Student&#44; el test U de Mann-Withney y ANOVA&#44; o el test de correlaci&#243;n de Pearson para variables continuas&#46; Para el c&#225;lculo de la supervivencia&#44; el m&#233;todo de Kaplan-Meier<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> y el test de log-rank<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">La tasa de prevalencia incluy&#243; todos los casos de CP encontrados en el estudio basal y aquellos que&#44; diagnosticados en el segundo control&#44; eran n&#243;dulos prevalentes&#46; La tasa de incidencia se calcul&#243; con los de nueva aparici&#243;n&#46; Los casos verdaderos positivos &#40;VP&#41; fueron casos CP prevalentes de cualquier estadio o casos diagnosticados en segundo control en estadio<span class="elsevierStyleHsp" style=""></span>I a partir de n&#243;dulos prevalentes&#46; Los falsos negativos &#40;FN&#41; fueron n&#243;dulos prevalentes que en control anual resultaron CP estadio &#62;<span class="elsevierStyleHsp" style=""></span>I y CP de intervalo&#46; Los valores de VP y FN fueron los mismos tanto al considerar casos de CP como casos de n&#243;dulos&#44; dado que&#44; aunque un sujeto pueda tener m&#225;s de un n&#243;dulo&#44; y no teniendo casos de CP multic&#233;ntrico&#44; se diagnostica como un solo CP&#46; Los falsos positivos &#40;FP&#41; fueron n&#243;dulos o pacientes con n&#243;dulos positivos&#44; seg&#250;n criterios radiol&#243;gicos&#44; en los que se indic&#243; alg&#250;n procedimiento diagn&#243;stico y no resultaron CP&#46; Los verdaderos negativos &#40;VN&#41; fueron los n&#243;dulos que no cumpl&#237;an criterios radiol&#243;gicos o sujetos que no presentaban n&#243;dulos o que&#44; present&#225;ndolos&#44; se mantuvieron estables o desaparecieron en el anual&#46; Se calcul&#243; la sensibilidad &#40;S&#41;&#44; la especificidad &#40;E&#41;&#44; la precisi&#243;n diagn&#243;stica &#40;PD&#41;&#44; los valores predictivos positivo &#40;VPP&#41; y negativo &#40;VPN&#41;&#44; las razones de verosimilitud o cocientes de probabilidades positivo &#40;RVP&#41; y negativo &#40;RVN&#41; para caracterizar la validez de la prueba&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Incluimos a 4&#46;951 sujetos en el estudio &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; De ellos el 65&#44;4&#37; eran varones y la media de edad era de 56&#44;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;26&#44; la mediana de 56&#44; con un rango comprendido en 50 y 79<span class="elsevierStyleHsp" style=""></span>a&#241;os&#46; El consumo medio de tabaco fue de 37&#44;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#44;41 a&#241;os-paquete para los hombres y de 29&#44;06<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;73 para las mujeres&#46; En el estudio basal&#44; 2&#46;238 &#40;45&#44;8&#37;&#41; eran exfumadores&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">En el estudio basal&#44; 4&#46;401 &#40;88&#44;89&#37;&#41; sujetos presentaron un TC negativo y 550 &#40;11&#44;11&#37;&#41; mostraban uno o m&#225;s n&#243;dulos que se determinaron como positivos&#46; De 3&#46;891 n&#243;dulos detectados&#44; 692 cumpl&#237;an criterios de positividad siguiendo el protocolo de I-ELCAP&#46; En base a este se decidieron las pautas de seguimiento&#46; En la mayor&#237;a de casos &#40;80&#44;20&#37;&#41; se indic&#243; un nuevo estudio con TCBD como primera actitud&#44; y en el 89&#44;36&#37; a los 3<span class="elsevierStyleHsp" style=""></span>meses&#46; En 23 &#40;3&#44;32&#37;&#41; de los casos se opt&#243; por un estudio histol&#243;gico&#44; en 21 &#40;3&#44;03&#37;&#41; por una PET-TC y en 5 casos por una broncoscopia &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; En dos casos&#44; a pesar de una PET negativa se indic&#243; biopsia&#44; dado el peque&#241;o tama&#241;o de los n&#243;dulos y la posibilidad de FP en la PET&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">En el estudio anual&#44; excluyendo los 36 sujetos diagnosticados de tumoraci&#243;n pulmonar&#44; 4&#46;691 &#40;95&#44;44&#37;&#41; participantes presentaron una TCBD negativa y 224 &#40;4&#44;56&#37;&#41; positiva&#44; detectando 4&#46;081 n&#243;dulos &#40;288 positivos&#41;&#46; En el 79&#44;86&#37; de los casos positivos se indic&#243; control con TCBD como primera opci&#243;n en el 46&#44;08&#37; al mes&#44; en el 47&#44;83&#37; a los 6<span class="elsevierStyleHsp" style=""></span>meses y en 44 casos TCBD anual&#46; Se indic&#243; PAAF en 6&#44; PET-TC en 3 y broncoscopia en 2&#46; Solo en uno se indic&#243; resecci&#243;n quir&#250;rgica diagn&#243;stica &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Se realizaron 40 biopsias en el estudio basal &#40;32<span class="elsevierStyleHsp" style=""></span>PAAF&#44; 6 broncoscopias&#44; una videocirug&#237;a y una toracotom&#237;a exploradora&#41; y 21 en el anual &#40;12<span class="elsevierStyleHsp" style=""></span>PAAF&#44; 7 broncoscopias y 2 toracotom&#237;as&#41;&#46; En el total de 44 PAAF realizadas se presentaron 6 neumot&#243;rax como &#250;nica complicaci&#243;n&#44; de los que solo 2 precisaron drenaje&#46; En el estudio basal&#44; 40 &#40;5&#44;8&#37;&#41; de los 692 n&#243;dulos clasificados como positivos precisaron procedimientos invasivos&#46; En el anual fueron el 7&#44;3&#37; &#40;21&#47;288 n&#243;dulos positivos&#41;&#46; Diagnosticamos 38 tumores pulmonares en el estudio basal&#44; de ellos 36<span class="elsevierStyleHsp" style=""></span>CP&#44; y 14 en el anual&#44; de los cuales 13<span class="elsevierStyleHsp" style=""></span>CP&#46; De estos&#44; 5 se diagnosticaron a partir de n&#243;dulos de nueva aparici&#243;n&#46; La tasa de prevalencia se estim&#243; en el 0&#44;89&#37;&#44; y la de incidencia&#44; en el 0&#44;1&#37;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Para la evaluaci&#243;n del programa y de la TCBD como herramienta diagn&#243;stica calculamos la S&#44; la E&#44; el VPP&#44; el VPN&#44; la RVP y la RVN sobre individuos y sobre n&#243;dulos &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">tablas 2 y 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">En el estudio basal&#44; 692 &#40;19&#44;57&#37;&#41; fueron dados como radiol&#243;gicamente positivos&#44; y de ellos&#44; 656 &#40;94&#44;8&#37;&#41; fueron considerados FP&#44; tras excluir los CP&#46; Considerando el total de n&#243;dulos no calcificados &#40;3&#46;536<span class="elsevierStyleHsp" style=""></span>NNC&#41;&#44; la tasa de FP fue del 18&#44;55&#37;&#46; En la ronda anual los FP supusieron el 96&#44;52&#37; respecto los n&#243;dulos dados como positivos&#44; y el 7&#44;64&#37; respecto el total de NNC&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Encontramos un total de 52 tumores&#44; 48 de ellos broncog&#233;nicos &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#44; una met&#225;stasis de melanoma &#40;primario desconocido&#41; y 3 tumores benignos &#40;tuberculoma&#44; histiocitosis<span class="elsevierStyleHsp" style=""></span>X&#44; aspergiloma&#41;&#46; El 52&#44;09&#37; de los tumores fueron diagnosticados en estadio<span class="elsevierStyleHsp" style=""></span>I &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46; Cuarenta &#40;76&#44;92&#37;&#41; CP fueron sometidos a tratamiento quir&#250;rgico&#46; La mediana de seguimiento fue de 3&#44;67 a&#241;os &#40;0&#44;01 a 7&#44;99&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">La supervivencia general de los CP detectados fue del 58&#44;5&#37; a los 5<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; siendo del 67&#44;1&#37; la supervivencia c&#225;ncer espec&#237;fica &#40;75&#44;8&#37; en los pacientes quir&#250;rgicos y 41&#37; en los no quir&#250;rgicos&#41;&#46; La supervivencia a los 5<span class="elsevierStyleHsp" style=""></span>a&#241;os entre los CP estadios IA fue del 89&#44;4&#37;&#44; y del 80&#37; entre los IB&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discusi&#243;n</span><p id="par0100" class="elsevierStylePara elsevierViewall">Este estudio presenta la TCBD como una herramienta v&#225;lida para el cribado del CP&#44; formando parte de un programa elaborado de detecci&#243;n precoz de n&#243;dulos pulmonares&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Existe una gran heterogeneidad entre los diferentes estudios tanto en los criterios de selecci&#243;n de participantes como en el dise&#241;o de los protocolos de evaluaci&#243;n de n&#243;dulos&#46; Como nosotros&#44; muchos de ellos recogen participantes voluntarios&#59; entre ellos el NLST<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a>&#44; que describe el &#171;efecto del voluntario sano&#187; como sujetos m&#225;s comprometidos con su salud y tambi&#233;n con el programa<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a>&#46; Sin duda&#44; seleccionar pacientes de mayor riesgo&#44; cohortes con mayor prevalencia de la enfermedad&#44; har&#237;a el cribado m&#225;s rentable&#46; Para ello&#44; el NELSON<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> seleccion&#243; su poblaci&#243;n entre los respondedores a cuestionarios&#59; otros estudios tienen en cuenta la existencia de EPOC&#47;enfisema<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a>&#44; y los hay que utilizan modelos predictivos de riesgo que valoran m&#250;ltiples factores y que&#44; sin duda&#44; mejoran la sensibilidad y el VPP<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">La proporci&#243;n de n&#243;dulos considerados radiol&#243;gicamente positivos en nuestro estudio fue del 19&#44;57&#37; en el basal y del 7&#44;91&#37; en el anual&#46; Comparado con los prevalentes&#44; los incidentes son menos frecuentes&#44; pero con mayor probabilidad de progresar a CP&#46; Henschke et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a>&#44; con los mismos criterios&#44; encuentran un 13&#37; de n&#243;dulos positivos&#46; La tasa del NLST<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> en la primera ronda fue del 27&#44;3&#37;&#46; El NELSON<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> la estima en el 2&#44;6&#37;&#44; aunque si tenemos en cuenta los n&#243;dulos que definen como indeterminados&#44; a los que realizan un control con TCBD a los 3<span class="elsevierStyleHsp" style=""></span>meses&#44; es del 19&#44;2&#37;&#46; En el presente estudio&#44; el 94&#44;8 y el 96&#44;52&#37; de los n&#243;dulos definidos como positivos en el estudio basal y anual&#44; respectivamente&#44; se podr&#237;an considerar FP&#44; aunque relacionado con el total de NNC&#44; supone una tasa de FP del 18&#44;55 y del 7&#44;64&#37;&#44; respectivamente&#46; En el NLST encuentran una tasa del 96&#37;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#44;19</span></a>&#46; En el NELSON&#44; en las tres primeras rondas&#44; sin incluir los n&#243;dulos indeterminados&#44; de los 493 test positivos hallaron 200<span class="elsevierStyleHsp" style=""></span>CP&#44; o sea&#44; el 64&#44;3&#37; de los positivos se pueden considerar FP&#46; Ellos estiman una tasa del 3&#44;86&#37;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a>&#46; Indudablemente&#44; la tasa de FP depende en gran medida de c&#243;mo se defina un positivo&#46; En opini&#243;n de los investigadores de I-ELCAP y el NELSON&#44; un n&#243;dulo que no presente crecimiento no se deber&#237;a considerar positivo&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">En cualquier caso&#44; la mayor&#237;a de los resultados positivos solo precisaron pruebas de imagen para su seguimiento&#46; En el estudio basal&#44; 40 &#40;5&#44;8&#37;&#41; de los 692 n&#243;dulos clasificados como positivos por la TCBD precisaron procedimientos invasivos&#44; y en el anual&#44; 20 &#40;7&#44;3&#37;&#41; de los 288 clasificados como positivos&#46; Resultaron positivas el 95 y el 66&#37; de las biopsias realizadas&#44; lo que traduce que el protocolo de evaluaci&#243;n permite seleccionar muy bien aquellos que realmente requieren una biopsia&#46; En la ronda anual&#44; la indicaci&#243;n de biopsia respond&#237;a al crecimiento de n&#243;dulos existentes o aparici&#243;n de nuevos &#40;que fueron la mayor&#237;a de ellos&#44; 275&#41;&#46; Los n&#243;dulos incidentes son menos frecuentes que los prevalentes&#44; pero con mayor probabilidad de malignidad&#46; Probablemente esta fue la raz&#243;n de tener un mayor n&#250;mero de biopsias con resultado de benignidad &#40;o no &#250;til para diagn&#243;stico&#41; en la ronda anual&#46; En cualquier caso&#44; las complicaciones iatrog&#233;nicas fueron escasas&#44; ninguna grave&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Como en otras series observacionales&#44; la tasa de prevalencia supera en mucho la de incidencia&#46; La tasa de prevalencia &#40;0&#44;89&#37;&#41; se acerca a la presentada por P-ELCAP &#40;1&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a>&#44; por Veronesi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> &#40;1&#44;1&#37;&#41; y por el I-ELCAP &#40;1&#44;3&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a>&#46; Encontramos una baja tasa de incidencia &#40;0&#44;1&#37;&#41; respecto otros estudios &#40;P-ELCAP<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a>&#44; 1&#44;4&#37;&#41;&#44; m&#225;s cercana al I-ELCAP &#40;0&#44;3&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> o a la tasa de detecci&#243;n anual de P-ELCAP &#40;0&#44;41&#37;&#41;&#44; diferencias que podr&#237;an explicarse por los diferentes criterios de inclusi&#243;n o que calculamos la tasa de incidencia solo con los n&#243;dulos de nueva aparici&#243;n&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">La S y la E&#44; tanto del protocolo de evaluaci&#243;n considerando individuos como de la TCBD considerando n&#243;dulos&#44; son muy altas&#46; El VPN es un par&#225;metro clave en cualquier programa de cribado&#44; y en nuestro caso fue del 99&#44;9&#37;&#46; El VPP definido como la probabilidad de estar enfermo cuando la prueba es positiva se situ&#243; en torno al 6&#44;55&#37;&#44; dato que se reproduce en otros estudios<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19&#44;22-25</span></a>&#46; Solo Henschke et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;26</span></a> encuentran una VPP del 11&#44;5&#37; en la primera ronda&#44; que aumenta al 25&#37; en rondas de incidencia&#46; Es el n&#250;mero de FP lo que condiciona el VPP bajo&#46; Dado la alta E y el elevado VPN hallados&#44; un resultado negativo hace altamente improbable que el individuo est&#233; enfermo&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">La PD&#44; entendido como porcentaje de pacientes que han sido diagnosticados correctamente&#44; fue del 89&#44;56 y del 95&#44;65&#37; en los estudios basal y anual&#44; respectivamente&#46; Para determinar la potencia diagn&#243;stica utilizamos las razones de verosimilitud&#46; La RVP que obtuvimos se puede interpretar como que es 9 o 18 veces &#40;basal&#47;anual&#41; m&#225;s probable encontrar un resultado positivo en un enfermo que en un sano&#46; Esta RVP en el estudio anual indica que es una prueba muy potente que apoya fuertemente el diagn&#243;stico&#46; Encontramos una RVN de 0&#44;09 en el estudio basal&#44; que indica que es una prueba muy potente para descartar el diagn&#243;stico&#46; No hay publicados datos similares de otros estudios&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">La prevalencia es&#44; en definitiva&#44; la probabilidad pre-prueba de estar enfermo&#46; La VPP ser&#237;a la probabilidad post-prueba de estar enfermo&#44; que se sit&#250;a entre el 5 y el 6&#44;5&#37;&#46; Conocemos la tasa de prevalencia poblacional del CP &#40;aprox&#46; 45 por 100&#46;000 habitantes&#41;&#46; Luego su cociente es 111-144&#44; lo que quiere decir que hemos multiplicado por 111-144 nuestra capacidad de detectar al enfermo&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La distribuci&#243;n por estadios de los CP diagnosticados es discretamente inferior a otros estudios&#58; en el NLST el 61&#44;6&#37; eran estadios IA-IB<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a>&#44; y en el NELSON lo fueron el 70&#44;8&#37;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a>&#46; P-ELCAP<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> encuentra el 73&#37; de los CP en estadio<span class="elsevierStyleHsp" style=""></span>I&#46; El porcentaje de estadios tempranos aumenta en rondas sucesivas &#40;resultados no presentados&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">El 76&#44;92&#37; de nuestros casos se sometieron a cirug&#237;a&#46; En I-ELCAP el 85&#37; de ellos se resecaron con una supervivencia a los 10<span class="elsevierStyleHsp" style=""></span>a&#241;os del 92&#37; cuando la intervenci&#243;n se realizaba en el primer mes del diagn&#243;stico<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a>&#46; La supervivencia c&#225;ncer-espec&#237;fica que encontramos fue del 67&#44;1&#37;&#44; y de 75&#44;8&#37; en el grupo de operados&#46; Otros estudios europeos encuentran datos similares&#58; Bellomi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> encuentran entre los CP diagnosticados en su estudio el 72&#37; en estadio<span class="elsevierStyleHsp" style=""></span>I&#44; con una supervivencia a 5<span class="elsevierStyleHsp" style=""></span>a&#241;os en este grupo del 89&#37;&#44; siendo la global del 63&#37;&#46; Blanchon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> encuentran una supervivencia entre los CP detectados en el grupo cribado con TC del 80&#37;&#44; y entre los CP en estadio<span class="elsevierStyleHsp" style=""></span>I&#44; del 88&#37;&#46; Estos datos resultan esperanzadores si recordamos la supervivencia global del CP en la poblaci&#243;n general&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Una de las principales limitaciones del cribado es el sobrediagn&#243;stico&#44; que no podemos valorar sin grupo control&#46; Con frecuencia se confunde este con el FP&#46; El FP es un error diagn&#243;stico&#44; y el sobrediagn&#243;stico es un error de pron&#243;stico<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">La TCBD integrada en un protocolo normalizado de evaluaci&#243;n con un algoritmo estudiado y definido &#40;con criterios de inclusi&#243;n delimitados&#44; que establezca durante cu&#225;nto tiempo y con qu&#233; periodicidad se realice el cribado&#41; es una herramienta v&#225;lida de cribado porque permite diagnosticar el CP en estadios m&#225;s tempranos&#46; Es importante minimizar todas las limitaciones antes de su implementaci&#243;n como cribado poblacional&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicto de intereses</span><p id="par0160" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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            0 => "Cribado de c&#225;ncer de pulm&#243;n"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introducci&#243;n</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El pron&#243;stico del c&#225;ncer de pulm&#243;n &#40;CP&#41; est&#225; relacionado directamente con el estadio de la enfermedad al diagn&#243;stico&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material y m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Realizamos TC de baja dosis &#40;TCBD&#41; a personas asintom&#225;ticas &#8805;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; fumadores o exfumadores de &#8805;<span class="elsevierStyleHsp" style=""></span>10 paquetes-a&#241;o&#44; sin antecedentes oncol&#243;gicos&#46; Seguimos un algoritmo de evaluaci&#243;n seg&#250;n el tama&#241;o y la morfolog&#237;a de los n&#243;dulos&#46; En los CP diagnosticados se estableci&#243; el tratamiento adecuado y el seguimiento fue de 5<span class="elsevierStyleHsp" style=""></span>a&#241;os&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Estudiamos 4&#46;951 personas &#40;65&#44;4&#37; varones&#41; con una media de edad de 56&#44;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;26<span class="elsevierStyleHsp" style=""></span>a&#241;os&#59; 550 presentaron n&#243;dulos&#46; De 3&#46;891 n&#243;dulos detectados&#44; 692 &#40;19&#44;57&#37;&#41; fueron considerados positivos&#44; hallando 38 tumores &#40;36<span class="elsevierStyleHsp" style=""></span>CP&#41;&#46; En el estudio anual&#44; 224 sujetos mostraban alg&#250;n n&#243;dulo&#44; siendo 288 &#40;7&#44;91&#37;&#41; positivos &#40;13<span class="elsevierStyleHsp" style=""></span>CP&#41;&#46; En el 80&#37; el control se realiz&#243; con TCBD y se indic&#243; biopsia en el 5&#44;8&#37; &#40;basal&#41; y 7&#44;6&#37; &#40;anual&#41; de los n&#243;dulos positivos&#46; La prevalencia fue del 0&#44;89 y la incidencia del 0&#44;1&#37;&#46; La sensibilidad&#44; la especificidad&#44; el VPP y el VPN en el estudio basal fueron del 92&#44;31&#44; del 89&#44;54&#44; del 6&#44;55 y del 99&#44;93&#37;&#44; respectivamente&#44; y en el anual&#44; del 76&#44;92&#44; del 95&#44;7&#44; del 4&#44;52 y del 99&#44;94&#37;&#44; respectivamente&#46; Se detectaron 52 tumores &#40;49<span class="elsevierStyleHsp" style=""></span>CP&#41;&#44; 25 &#40;52&#44;08&#37;&#41; en estadio<span class="elsevierStyleHsp" style=""></span>I&#46; La supervivencia global de los CP fue del 58&#44;5&#37; a los 5<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; y la supervivencia c&#225;ncer espec&#237;fica&#44; del 67&#44;1&#37; &#40;75&#44;8&#37; en los pacientes quir&#250;rgicos&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La TCBD integrada en un programa elaborado de detecci&#243;n y evaluaci&#243;n de n&#243;dulos es una herramienta &#250;til para diagnosticar CP en estadio precoz&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The prognosis of lung cancer &#40;LC&#41; correlates directly with the stage of the disease at the time of diagnosis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Material and methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We performed low-dose CT &#40;LDCT&#41; in asymptomatic individuals &#8805;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>years old&#44; smokers or former smokers of &#8805;<span class="elsevierStyleHsp" style=""></span>10 pack-years&#44; with no history of cancer&#46; We followed an evaluation algorithm&#44; according to the size and morphology of the nodules&#46; The appropriate treatment for the LC diagnosis was given and patients were followed up for 5<span class="elsevierStyleHsp" style=""></span>years&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">We studied 4&#44;951 individuals &#40;65&#46;4&#37; males&#41; with an average age of 56&#46;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;26<span class="elsevierStyleHsp" style=""></span>years&#59; 550 presented nodules&#46; Of the 3&#44;891 nodules detected&#44; 692 &#40;19&#46;57&#37;&#41; were considered positive&#44; and 38 tumors &#40;36<span class="elsevierStyleHsp" style=""></span>LC&#41; were identified&#46; In the annual follow-up&#44; nodules were found in 224 subjects&#44; 288 &#40;7&#46;91&#37;&#41; of which were positive &#40;13<span class="elsevierStyleHsp" style=""></span>LC&#41;&#46; In 80&#37;&#44; the study was performed with LDCT&#44; and biopsy was indicated in 5&#46;8&#37; &#40;baseline&#41; and in 7&#46;6&#37; &#40;annual&#41; of the positive nodules&#46; Prevalence was 0&#46;89 and incidence was 0&#46;1&#37;&#46; The sensitivity&#44; specificity&#44; PPV and NPV in the baseline study were 92&#46;31&#44; 89&#46;54&#44; 6&#46;55 and 99&#46;93&#37;&#44; respectively&#44; and in the annual study&#44; they were 76&#46;92&#44; 95&#46;7&#44; 4&#46;52 and 99&#46;94&#37;&#44; respectively&#46; A total of 52 tumors were detected &#40;49<span class="elsevierStyleHsp" style=""></span>LC&#41;&#44; 25 &#40;52&#46;08&#37;&#41; in stage<span class="elsevierStyleHsp" style=""></span>I&#46; The 5-year overall survival rate for LC was 58&#46;5&#37; and cancer-specific survival was 67&#46;1&#37; &#40;75&#46;8&#37; in surgical patients&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">LDCT integrated into an elaborate nodule detection and evaluation program is a useful tool for diagnosing early-stage LC&#46;</p></span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sexo&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">Hombres&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">3&#46;237 &#40;65&#44;4&#37;&#41;&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">Mujeres&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;714 &#40;34&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Edad&#44; a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50-60&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">3&#46;905 &#40;78&#44;87&#37;&#41;&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">61-70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">942 &#40;19&#44;02&#37;&#41;&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">&#62;<span class="elsevierStyleHsp" style=""></span>70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">104 &#40;2&#44;01&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">H&#225;bito tabaco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fumadores activos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;713 &#40;54&#44;8&#37;&#41;&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">Exfumadores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;238 &#40;45&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&#241;os-paquete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#44;53&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">Hombres&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#44;45&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">Mujeres&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#44;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antecedentes familiares CP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">933 &#40;18&#44;84&#37;&#41;&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">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;913 &#40;79&#44;04&#37;&#41;&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">No sabe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">105 &#40;2&#44;12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Contacto asbesto&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">417 &#40;8&#44;42&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antecedentes respiratorios&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neumon&#237;a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">195 &#40;3&#44;94&#37;&#41;&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">Enfisema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">253 &#40;5&#44;11&#41;&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">Asma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">159 &#40;3&#44;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas de la poblaci&#243;n de estudio</p>"
        ]
      ]
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Individuos&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
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#243;dulos&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></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">VP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Con diferenciaci&#243;n ent&#233;rica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  """
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Original
Diagnóstico precoz del cáncer de pulmón: utilidad de la tomografía computarizada de baja dosis de radiación
Lung Cancer Screening: Use of Low-Dose Computed Tomography
Encarnación Martínez Péreza,
Corresponding author
emperez20@hotmail.com

Autor para correspondencia.
, Karol de Aguiar Quevedob, Miguel Arrarás Martínezb, Julia Cruz Mojarrietac, Estanislao Arana Fernández de Moyad, María Barrios Benitod, Susana Hinarejos Pargae, José Cervera Devald, Juan Carlos Peñalver Cuestab
a Unidad de Neumología, Servicio de Cirugía Torácica, Fundación Instituto Valenciano de Oncología, Valencia, España
b Servicio de Cirugía Torácica, Fundación Instituto Valenciano de Oncología, Valencia, España
c Servicio de Anatomía Patológica, Fundación Instituto Valenciano de Oncología, Valencia, España
d Servicio de Radiodiagnóstico, Fundación Instituto Valenciano de Oncología, Valencia, España
e Unidad de Diagnóstico Precoz de Cáncer de Pulmón, Fundación Instituto Valenciano de Oncología, Valencia, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">El c&#225;ncer de pulm&#243;n &#40;CP&#41; supone un importante problema de salud&#58; es uno de los tipos de c&#225;ncer m&#225;s frecuentes y el que presenta una mayor mortalidad&#46; Su supervivencia global a los 5<span class="elsevierStyleHsp" style=""></span>a&#241;os no supera el 16&#37;&#44; pron&#243;stico que est&#225; directamente relacionado con el estadio de la enfermedad en el momento del diagn&#243;stico&#46; La prevenci&#243;n primaria del tabaquismo es clave para reducir su incidencia&#44; y el mayor n&#250;mero de casos se diagnostica entre exfumadores&#46; Aun con esta prevenci&#243;n primaria y los recientes avances en el tratamiento&#44; el diagn&#243;stico precoz de la enfermedad es la clave para reducir su mortalidad&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El <span class="elsevierStyleItalic">International Early Lung Cancer Action Program</span> &#40;I-ELCAP&#41;&#44; estudio no aleatorizado&#44; ya en 2006 publicaba que el 85&#37; de los c&#225;nceres diagnosticados se encontraban en estadio<span class="elsevierStyleHsp" style=""></span>I&#44; con una supervivencia estimada a los 10<span class="elsevierStyleHsp" style=""></span>a&#241;os del 88&#37;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> &#40;del 92&#37; si los CP en estadio<span class="elsevierStyleHsp" style=""></span>I se resecaban antes del primer mes desde el diagn&#243;stico&#41;&#46; El <span class="elsevierStyleItalic">National Lung Screening Trial</span> &#40;NLST&#41; es el primer estudio de cribado aleatorizado en personas de alto riesgo que mostr&#243; una reducci&#243;n de la mortalidad por CP&#58; del 20&#44;3&#37; en el grupo cribado con TC de baja dosis &#40;TCBD&#41; frente la radiograf&#237;a de t&#243;rax&#44; y del 6&#44;7&#37; en la mortalidad global<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a>&#46; Estos resultados motivaron que la <span class="elsevierStyleItalic">U&#46;S&#46; Preventive Services Task Force</span> &#40;USPSTF&#41; recomendara en 2014 el cribado en sujetos de alto riesgo con un grado de evidencia 2B<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a>&#46; La <span class="elsevierStyleItalic">European Society of Radiology</span> &#40;ESR&#41; y la <span class="elsevierStyleItalic">European Respiratory Society</span> &#40;ERS&#41; mostraron en 2015 su apoyo al cribado<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a>&#46; Recientemente&#44; la <span class="elsevierStyleItalic">International Association for the Study of Lung Cancer</span> &#40;IASLC&#41; ha recomendado la implementaci&#243;n del cribado bas&#225;ndose en los resultados del estudio NELSON <span class="elsevierStyleItalic">&#40;NEderlands-leuvens Longkanker Screenings ONderzoek&#41;</span> presentados en la <span class="elsevierStyleItalic">IASLC 19th World Conference of Lung Cancer</span> en Toronto&#46; Confirma que el cribado con TCBD reduce la mortalidad por CP el 26&#37; en varones y hasta el 61&#37; en mujeres&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En Espa&#241;a contamos con la amplia experiencia de la Cl&#237;nica Universitaria de Navarra<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a>&#44; que tambi&#233;n forma parte de I-ELCAP&#44; aportando importantes contribuciones al cribado&#58; uso de la tomograf&#237;a por emisi&#243;n de positrones &#40;PET&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a>&#44; valor del enfisema y la enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> y creaci&#243;n de modelos predictivos de riesgo<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Apoyando las reflexiones sobre la implementaci&#243;n del cribado que la Sociedad Espa&#241;ola de Neumolog&#237;a y Cirug&#237;a Tor&#225;cica&#44; junto con otras sociedades&#44; public&#243; en 2017<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a>&#44; pretendemos mostrar con nuestros datos que la TCBD integrada en un protocolo estructurado permite detectar CP en estadios tempranos potencialmente curables&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Poblaci&#243;n de estudio</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se incluyeron personas que entraron en el programa de cribado de CP de la Fundaci&#243;n IVO entre junio de 2008 y diciembre de 2012&#44; formando parte de una cohorte internacional en el programa I-ELCAP&#46; Cumpl&#237;an los siguientes criterios&#58; edad &#8805;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; fumadores o exfumadores con un h&#225;bito acumulado de&#44; al menos&#44; 10<span class="elsevierStyleHsp" style=""></span>paquetes-a&#241;o&#44; sin antecedentes personales de procesos oncol&#243;gicos &#40;excepto carcinomas basocelulares de piel&#41; y sin s&#237;ntomas sugestivos de CP&#46; Todos ellos fueron voluntarios &#40;algunos remitidos por su m&#233;dico de atenci&#243;n primaria&#44; la mayor&#237;a informados por otros participantes&#41; y&#44; tras ser informados del estudio y del riesgo de las t&#233;cnicas diagn&#243;sticas&#44; firmaron un documento de consentimiento aprobado por el comit&#233; de &#233;tica del hospital&#46; El seguimiento de los casos de CP diagnosticados finaliz&#243; el 31 de diciembre de 2016&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Algoritmo diagn&#243;stico</span><p id="par0030" class="elsevierStylePara elsevierViewall">Todas las exploraciones de TC se realizan con un TC helicoidal multidetector de 16 filas &#40;Siemens Emotion 16&#44; Erlangen&#44; Alemania&#41;&#46; Las im&#225;genes se adquirieron con par&#225;metros de baja dosis de radiaci&#243;n &#40;&#8804;<span class="elsevierStyleHsp" style=""></span>120<span class="elsevierStyleHsp" style=""></span>kVps y &#8804;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mAs&#41; con <span class="elsevierStyleItalic">CT Dose Index volumen</span> &#706;<span class="elsevierStyleHsp" style=""></span>2&#44;13<span class="elsevierStyleHsp" style=""></span>mGy y dep&#243;sito de energ&#237;a DLP <span class="elsevierStyleItalic">&#40;Dose Length Product&#41;</span> en el rango de 80-100<span class="elsevierStyleHsp" style=""></span>mGy&#42;cm&#46; El grosor de corte para par&#233;nquima pulmonar fue de 1<span class="elsevierStyleHsp" style=""></span>mm y para mediastino&#44; de 5<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A todos los participantes se les realiz&#243; un estudio basal y&#44; como m&#237;nimo&#44; otro estudio al a&#241;o&#46; Siguiendo el protocolo diagn&#243;stico de I-ELCAP &#40;<a href="http://www.ielcap.org/">www&#46;ielcap&#46;org</a>&#41; se identific&#243; y caracteriz&#243; los n&#243;dulos pulmonares hallados&#44; as&#237; como otros hallazgos en t&#243;rax-abdomen superior&#46; Se consider&#243; el estudio basal positivo ante n&#243;dulos no calcificados &#40;NNC&#41; s&#243;lidos o parcialmente s&#243;lidos de &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm o n&#243;dulos no s&#243;lidos &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mm&#46; En dicho caso se opt&#243; por control con TCBD en 3<span class="elsevierStyleHsp" style=""></span>meses&#44; PET-TC o biopsia seg&#250;n criterios de tama&#241;o o altamente sugestivos de malignidad&#46; Si hubo sospecha de infecci&#243;n&#44; se recomend&#243; un tratamiento antibi&#243;tico y control con TCBD al mes&#46; Si se evidenci&#243; una resoluci&#243;n parcial o completa&#44; el siguiente control se realiz&#243; al a&#241;o&#46; Los casos donde el estudio basal fue dado como negativo&#44; el siguiente control se realiz&#243; al a&#241;o&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">En el control anual se evalu&#243; la aparici&#243;n de nuevos n&#243;dulos&#44; el crecimiento de los existentes y todos los par&#225;metros del TCBD inicial&#46; Se consider&#243; positivo la aparici&#243;n de un n&#243;dulo s&#243;lido o parcialmente s&#243;lido de &#8805;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mm&#44; no s&#243;lido &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mm o un n&#243;dulo endobronquial s&#243;lido de &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm&#46; Se consideraron semipositivos los n&#243;dulos s&#243;lidos &#706;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mm o no s&#243;lidos &#706;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mm&#44; realizando un TCBD anual&#46; Ante n&#243;dulos s&#243;lidos entre 3 y 5<span class="elsevierStyleHsp" style=""></span>mm se realiz&#243; control TCBD en 6<span class="elsevierStyleHsp" style=""></span>meses&#46; En im&#225;genes sospechosas de un proceso infeccioso se recomend&#243; tratamiento antibi&#243;tico&#46; Si no se encontraron cambios ni nuevos n&#243;dulos&#44; se indic&#243; TCBD anual&#46; El crecimiento de un n&#243;dulo se defini&#243; como el aumento del mismo o de su componente s&#243;lido&#44; as&#237; como el tiempo de duplicaci&#243;n&#46; Si se precis&#243; biopsia&#44; se eligi&#243; la mejor t&#233;cnica seg&#250;n la localizaci&#243;n de la lesi&#243;n&#46; La m&#225;s empleada fue la punci&#243;n transtor&#225;cica guiada por TC&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">En los casos en que se lleg&#243; a un diagn&#243;stico de CP se complet&#243; el estudio de extensi&#243;n para estadificar la enfermedad&#44; conocer la resecabilidad del tumor y la operabilidad del paciente&#46; El tratamiento electivo se decidi&#243; de forma individual en consenso en el comit&#233; multidisciplinar de CP de nuestro hospital&#46; La clasificaci&#243;n TNM empleada en el presente trabajo corresponde a la octava edici&#243;n<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis estad&#237;stico</span><p id="par0050" class="elsevierStylePara elsevierViewall">Las diferentes variables demogr&#225;ficas&#44; radiol&#243;gicas&#44; caracter&#237;sticas de los CP diagnosticados&#44; etc&#46;&#44; se analizaron con el paquete estad&#237;stico para Windows<span class="elsevierStyleSup">&#174;</span> SPSS<span class="elsevierStyleSup">&#174;</span> versi&#243;n 22&#46; Se realiz&#243; un an&#225;lisis descriptivo y comparativo&#44; utilizando para este el m&#233;todo de chi-cuadrado &#40;&#967;<span class="elsevierStyleSup">2</span>&#41; o el test exacto de Fisher&#44; la t de Student&#44; el test U de Mann-Withney y ANOVA&#44; o el test de correlaci&#243;n de Pearson para variables continuas&#46; Para el c&#225;lculo de la supervivencia&#44; el m&#233;todo de Kaplan-Meier<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> y el test de log-rank<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">La tasa de prevalencia incluy&#243; todos los casos de CP encontrados en el estudio basal y aquellos que&#44; diagnosticados en el segundo control&#44; eran n&#243;dulos prevalentes&#46; La tasa de incidencia se calcul&#243; con los de nueva aparici&#243;n&#46; Los casos verdaderos positivos &#40;VP&#41; fueron casos CP prevalentes de cualquier estadio o casos diagnosticados en segundo control en estadio<span class="elsevierStyleHsp" style=""></span>I a partir de n&#243;dulos prevalentes&#46; Los falsos negativos &#40;FN&#41; fueron n&#243;dulos prevalentes que en control anual resultaron CP estadio &#62;<span class="elsevierStyleHsp" style=""></span>I y CP de intervalo&#46; Los valores de VP y FN fueron los mismos tanto al considerar casos de CP como casos de n&#243;dulos&#44; dado que&#44; aunque un sujeto pueda tener m&#225;s de un n&#243;dulo&#44; y no teniendo casos de CP multic&#233;ntrico&#44; se diagnostica como un solo CP&#46; Los falsos positivos &#40;FP&#41; fueron n&#243;dulos o pacientes con n&#243;dulos positivos&#44; seg&#250;n criterios radiol&#243;gicos&#44; en los que se indic&#243; alg&#250;n procedimiento diagn&#243;stico y no resultaron CP&#46; Los verdaderos negativos &#40;VN&#41; fueron los n&#243;dulos que no cumpl&#237;an criterios radiol&#243;gicos o sujetos que no presentaban n&#243;dulos o que&#44; present&#225;ndolos&#44; se mantuvieron estables o desaparecieron en el anual&#46; Se calcul&#243; la sensibilidad &#40;S&#41;&#44; la especificidad &#40;E&#41;&#44; la precisi&#243;n diagn&#243;stica &#40;PD&#41;&#44; los valores predictivos positivo &#40;VPP&#41; y negativo &#40;VPN&#41;&#44; las razones de verosimilitud o cocientes de probabilidades positivo &#40;RVP&#41; y negativo &#40;RVN&#41; para caracterizar la validez de la prueba&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Incluimos a 4&#46;951 sujetos en el estudio &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; De ellos el 65&#44;4&#37; eran varones y la media de edad era de 56&#44;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;26&#44; la mediana de 56&#44; con un rango comprendido en 50 y 79<span class="elsevierStyleHsp" style=""></span>a&#241;os&#46; El consumo medio de tabaco fue de 37&#44;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#44;41 a&#241;os-paquete para los hombres y de 29&#44;06<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;73 para las mujeres&#46; En el estudio basal&#44; 2&#46;238 &#40;45&#44;8&#37;&#41; eran exfumadores&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">En el estudio basal&#44; 4&#46;401 &#40;88&#44;89&#37;&#41; sujetos presentaron un TC negativo y 550 &#40;11&#44;11&#37;&#41; mostraban uno o m&#225;s n&#243;dulos que se determinaron como positivos&#46; De 3&#46;891 n&#243;dulos detectados&#44; 692 cumpl&#237;an criterios de positividad siguiendo el protocolo de I-ELCAP&#46; En base a este se decidieron las pautas de seguimiento&#46; En la mayor&#237;a de casos &#40;80&#44;20&#37;&#41; se indic&#243; un nuevo estudio con TCBD como primera actitud&#44; y en el 89&#44;36&#37; a los 3<span class="elsevierStyleHsp" style=""></span>meses&#46; En 23 &#40;3&#44;32&#37;&#41; de los casos se opt&#243; por un estudio histol&#243;gico&#44; en 21 &#40;3&#44;03&#37;&#41; por una PET-TC y en 5 casos por una broncoscopia &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; En dos casos&#44; a pesar de una PET negativa se indic&#243; biopsia&#44; dado el peque&#241;o tama&#241;o de los n&#243;dulos y la posibilidad de FP en la PET&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">En el estudio anual&#44; excluyendo los 36 sujetos diagnosticados de tumoraci&#243;n pulmonar&#44; 4&#46;691 &#40;95&#44;44&#37;&#41; participantes presentaron una TCBD negativa y 224 &#40;4&#44;56&#37;&#41; positiva&#44; detectando 4&#46;081 n&#243;dulos &#40;288 positivos&#41;&#46; En el 79&#44;86&#37; de los casos positivos se indic&#243; control con TCBD como primera opci&#243;n en el 46&#44;08&#37; al mes&#44; en el 47&#44;83&#37; a los 6<span class="elsevierStyleHsp" style=""></span>meses y en 44 casos TCBD anual&#46; Se indic&#243; PAAF en 6&#44; PET-TC en 3 y broncoscopia en 2&#46; Solo en uno se indic&#243; resecci&#243;n quir&#250;rgica diagn&#243;stica &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Se realizaron 40 biopsias en el estudio basal &#40;32<span class="elsevierStyleHsp" style=""></span>PAAF&#44; 6 broncoscopias&#44; una videocirug&#237;a y una toracotom&#237;a exploradora&#41; y 21 en el anual &#40;12<span class="elsevierStyleHsp" style=""></span>PAAF&#44; 7 broncoscopias y 2 toracotom&#237;as&#41;&#46; En el total de 44 PAAF realizadas se presentaron 6 neumot&#243;rax como &#250;nica complicaci&#243;n&#44; de los que solo 2 precisaron drenaje&#46; En el estudio basal&#44; 40 &#40;5&#44;8&#37;&#41; de los 692 n&#243;dulos clasificados como positivos precisaron procedimientos invasivos&#46; En el anual fueron el 7&#44;3&#37; &#40;21&#47;288 n&#243;dulos positivos&#41;&#46; Diagnosticamos 38 tumores pulmonares en el estudio basal&#44; de ellos 36<span class="elsevierStyleHsp" style=""></span>CP&#44; y 14 en el anual&#44; de los cuales 13<span class="elsevierStyleHsp" style=""></span>CP&#46; De estos&#44; 5 se diagnosticaron a partir de n&#243;dulos de nueva aparici&#243;n&#46; La tasa de prevalencia se estim&#243; en el 0&#44;89&#37;&#44; y la de incidencia&#44; en el 0&#44;1&#37;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Para la evaluaci&#243;n del programa y de la TCBD como herramienta diagn&#243;stica calculamos la S&#44; la E&#44; el VPP&#44; el VPN&#44; la RVP y la RVN sobre individuos y sobre n&#243;dulos &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">tablas 2 y 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">En el estudio basal&#44; 692 &#40;19&#44;57&#37;&#41; fueron dados como radiol&#243;gicamente positivos&#44; y de ellos&#44; 656 &#40;94&#44;8&#37;&#41; fueron considerados FP&#44; tras excluir los CP&#46; Considerando el total de n&#243;dulos no calcificados &#40;3&#46;536<span class="elsevierStyleHsp" style=""></span>NNC&#41;&#44; la tasa de FP fue del 18&#44;55&#37;&#46; En la ronda anual los FP supusieron el 96&#44;52&#37; respecto los n&#243;dulos dados como positivos&#44; y el 7&#44;64&#37; respecto el total de NNC&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Encontramos un total de 52 tumores&#44; 48 de ellos broncog&#233;nicos &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#44; una met&#225;stasis de melanoma &#40;primario desconocido&#41; y 3 tumores benignos &#40;tuberculoma&#44; histiocitosis<span class="elsevierStyleHsp" style=""></span>X&#44; aspergiloma&#41;&#46; El 52&#44;09&#37; de los tumores fueron diagnosticados en estadio<span class="elsevierStyleHsp" style=""></span>I &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46; Cuarenta &#40;76&#44;92&#37;&#41; CP fueron sometidos a tratamiento quir&#250;rgico&#46; La mediana de seguimiento fue de 3&#44;67 a&#241;os &#40;0&#44;01 a 7&#44;99&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">La supervivencia general de los CP detectados fue del 58&#44;5&#37; a los 5<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; siendo del 67&#44;1&#37; la supervivencia c&#225;ncer espec&#237;fica &#40;75&#44;8&#37; en los pacientes quir&#250;rgicos y 41&#37; en los no quir&#250;rgicos&#41;&#46; La supervivencia a los 5<span class="elsevierStyleHsp" style=""></span>a&#241;os entre los CP estadios IA fue del 89&#44;4&#37;&#44; y del 80&#37; entre los IB&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discusi&#243;n</span><p id="par0100" class="elsevierStylePara elsevierViewall">Este estudio presenta la TCBD como una herramienta v&#225;lida para el cribado del CP&#44; formando parte de un programa elaborado de detecci&#243;n precoz de n&#243;dulos pulmonares&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Existe una gran heterogeneidad entre los diferentes estudios tanto en los criterios de selecci&#243;n de participantes como en el dise&#241;o de los protocolos de evaluaci&#243;n de n&#243;dulos&#46; Como nosotros&#44; muchos de ellos recogen participantes voluntarios&#59; entre ellos el NLST<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a>&#44; que describe el &#171;efecto del voluntario sano&#187; como sujetos m&#225;s comprometidos con su salud y tambi&#233;n con el programa<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a>&#46; Sin duda&#44; seleccionar pacientes de mayor riesgo&#44; cohortes con mayor prevalencia de la enfermedad&#44; har&#237;a el cribado m&#225;s rentable&#46; Para ello&#44; el NELSON<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> seleccion&#243; su poblaci&#243;n entre los respondedores a cuestionarios&#59; otros estudios tienen en cuenta la existencia de EPOC&#47;enfisema<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a>&#44; y los hay que utilizan modelos predictivos de riesgo que valoran m&#250;ltiples factores y que&#44; sin duda&#44; mejoran la sensibilidad y el VPP<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">La proporci&#243;n de n&#243;dulos considerados radiol&#243;gicamente positivos en nuestro estudio fue del 19&#44;57&#37; en el basal y del 7&#44;91&#37; en el anual&#46; Comparado con los prevalentes&#44; los incidentes son menos frecuentes&#44; pero con mayor probabilidad de progresar a CP&#46; Henschke et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a>&#44; con los mismos criterios&#44; encuentran un 13&#37; de n&#243;dulos positivos&#46; La tasa del NLST<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> en la primera ronda fue del 27&#44;3&#37;&#46; El NELSON<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> la estima en el 2&#44;6&#37;&#44; aunque si tenemos en cuenta los n&#243;dulos que definen como indeterminados&#44; a los que realizan un control con TCBD a los 3<span class="elsevierStyleHsp" style=""></span>meses&#44; es del 19&#44;2&#37;&#46; En el presente estudio&#44; el 94&#44;8 y el 96&#44;52&#37; de los n&#243;dulos definidos como positivos en el estudio basal y anual&#44; respectivamente&#44; se podr&#237;an considerar FP&#44; aunque relacionado con el total de NNC&#44; supone una tasa de FP del 18&#44;55 y del 7&#44;64&#37;&#44; respectivamente&#46; En el NLST encuentran una tasa del 96&#37;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#44;19</span></a>&#46; En el NELSON&#44; en las tres primeras rondas&#44; sin incluir los n&#243;dulos indeterminados&#44; de los 493 test positivos hallaron 200<span class="elsevierStyleHsp" style=""></span>CP&#44; o sea&#44; el 64&#44;3&#37; de los positivos se pueden considerar FP&#46; Ellos estiman una tasa del 3&#44;86&#37;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a>&#46; Indudablemente&#44; la tasa de FP depende en gran medida de c&#243;mo se defina un positivo&#46; En opini&#243;n de los investigadores de I-ELCAP y el NELSON&#44; un n&#243;dulo que no presente crecimiento no se deber&#237;a considerar positivo&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">En cualquier caso&#44; la mayor&#237;a de los resultados positivos solo precisaron pruebas de imagen para su seguimiento&#46; En el estudio basal&#44; 40 &#40;5&#44;8&#37;&#41; de los 692 n&#243;dulos clasificados como positivos por la TCBD precisaron procedimientos invasivos&#44; y en el anual&#44; 20 &#40;7&#44;3&#37;&#41; de los 288 clasificados como positivos&#46; Resultaron positivas el 95 y el 66&#37; de las biopsias realizadas&#44; lo que traduce que el protocolo de evaluaci&#243;n permite seleccionar muy bien aquellos que realmente requieren una biopsia&#46; En la ronda anual&#44; la indicaci&#243;n de biopsia respond&#237;a al crecimiento de n&#243;dulos existentes o aparici&#243;n de nuevos &#40;que fueron la mayor&#237;a de ellos&#44; 275&#41;&#46; Los n&#243;dulos incidentes son menos frecuentes que los prevalentes&#44; pero con mayor probabilidad de malignidad&#46; Probablemente esta fue la raz&#243;n de tener un mayor n&#250;mero de biopsias con resultado de benignidad &#40;o no &#250;til para diagn&#243;stico&#41; en la ronda anual&#46; En cualquier caso&#44; las complicaciones iatrog&#233;nicas fueron escasas&#44; ninguna grave&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Como en otras series observacionales&#44; la tasa de prevalencia supera en mucho la de incidencia&#46; La tasa de prevalencia &#40;0&#44;89&#37;&#41; se acerca a la presentada por P-ELCAP &#40;1&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a>&#44; por Veronesi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> &#40;1&#44;1&#37;&#41; y por el I-ELCAP &#40;1&#44;3&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a>&#46; Encontramos una baja tasa de incidencia &#40;0&#44;1&#37;&#41; respecto otros estudios &#40;P-ELCAP<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a>&#44; 1&#44;4&#37;&#41;&#44; m&#225;s cercana al I-ELCAP &#40;0&#44;3&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> o a la tasa de detecci&#243;n anual de P-ELCAP &#40;0&#44;41&#37;&#41;&#44; diferencias que podr&#237;an explicarse por los diferentes criterios de inclusi&#243;n o que calculamos la tasa de incidencia solo con los n&#243;dulos de nueva aparici&#243;n&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">La S y la E&#44; tanto del protocolo de evaluaci&#243;n considerando individuos como de la TCBD considerando n&#243;dulos&#44; son muy altas&#46; El VPN es un par&#225;metro clave en cualquier programa de cribado&#44; y en nuestro caso fue del 99&#44;9&#37;&#46; El VPP definido como la probabilidad de estar enfermo cuando la prueba es positiva se situ&#243; en torno al 6&#44;55&#37;&#44; dato que se reproduce en otros estudios<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19&#44;22-25</span></a>&#46; Solo Henschke et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;26</span></a> encuentran una VPP del 11&#44;5&#37; en la primera ronda&#44; que aumenta al 25&#37; en rondas de incidencia&#46; Es el n&#250;mero de FP lo que condiciona el VPP bajo&#46; Dado la alta E y el elevado VPN hallados&#44; un resultado negativo hace altamente improbable que el individuo est&#233; enfermo&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">La PD&#44; entendido como porcentaje de pacientes que han sido diagnosticados correctamente&#44; fue del 89&#44;56 y del 95&#44;65&#37; en los estudios basal y anual&#44; respectivamente&#46; Para determinar la potencia diagn&#243;stica utilizamos las razones de verosimilitud&#46; La RVP que obtuvimos se puede interpretar como que es 9 o 18 veces &#40;basal&#47;anual&#41; m&#225;s probable encontrar un resultado positivo en un enfermo que en un sano&#46; Esta RVP en el estudio anual indica que es una prueba muy potente que apoya fuertemente el diagn&#243;stico&#46; Encontramos una RVN de 0&#44;09 en el estudio basal&#44; que indica que es una prueba muy potente para descartar el diagn&#243;stico&#46; No hay publicados datos similares de otros estudios&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">La prevalencia es&#44; en definitiva&#44; la probabilidad pre-prueba de estar enfermo&#46; La VPP ser&#237;a la probabilidad post-prueba de estar enfermo&#44; que se sit&#250;a entre el 5 y el 6&#44;5&#37;&#46; Conocemos la tasa de prevalencia poblacional del CP &#40;aprox&#46; 45 por 100&#46;000 habitantes&#41;&#46; Luego su cociente es 111-144&#44; lo que quiere decir que hemos multiplicado por 111-144 nuestra capacidad de detectar al enfermo&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La distribuci&#243;n por estadios de los CP diagnosticados es discretamente inferior a otros estudios&#58; en el NLST el 61&#44;6&#37; eran estadios IA-IB<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a>&#44; y en el NELSON lo fueron el 70&#44;8&#37;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a>&#46; P-ELCAP<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> encuentra el 73&#37; de los CP en estadio<span class="elsevierStyleHsp" style=""></span>I&#46; El porcentaje de estadios tempranos aumenta en rondas sucesivas &#40;resultados no presentados&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">El 76&#44;92&#37; de nuestros casos se sometieron a cirug&#237;a&#46; En I-ELCAP el 85&#37; de ellos se resecaron con una supervivencia a los 10<span class="elsevierStyleHsp" style=""></span>a&#241;os del 92&#37; cuando la intervenci&#243;n se realizaba en el primer mes del diagn&#243;stico<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a>&#46; La supervivencia c&#225;ncer-espec&#237;fica que encontramos fue del 67&#44;1&#37;&#44; y de 75&#44;8&#37; en el grupo de operados&#46; Otros estudios europeos encuentran datos similares&#58; Bellomi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> encuentran entre los CP diagnosticados en su estudio el 72&#37; en estadio<span class="elsevierStyleHsp" style=""></span>I&#44; con una supervivencia a 5<span class="elsevierStyleHsp" style=""></span>a&#241;os en este grupo del 89&#37;&#44; siendo la global del 63&#37;&#46; Blanchon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> encuentran una supervivencia entre los CP detectados en el grupo cribado con TC del 80&#37;&#44; y entre los CP en estadio<span class="elsevierStyleHsp" style=""></span>I&#44; del 88&#37;&#46; Estos datos resultan esperanzadores si recordamos la supervivencia global del CP en la poblaci&#243;n general&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Una de las principales limitaciones del cribado es el sobrediagn&#243;stico&#44; que no podemos valorar sin grupo control&#46; Con frecuencia se confunde este con el FP&#46; El FP es un error diagn&#243;stico&#44; y el sobrediagn&#243;stico es un error de pron&#243;stico<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">La TCBD integrada en un protocolo normalizado de evaluaci&#243;n con un algoritmo estudiado y definido &#40;con criterios de inclusi&#243;n delimitados&#44; que establezca durante cu&#225;nto tiempo y con qu&#233; periodicidad se realice el cribado&#41; es una herramienta v&#225;lida de cribado porque permite diagnosticar el CP en estadios m&#225;s tempranos&#46; Es importante minimizar todas las limitaciones antes de su implementaci&#243;n como cribado poblacional&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicto de intereses</span><p id="par0160" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introducci&#243;n</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El pron&#243;stico del c&#225;ncer de pulm&#243;n &#40;CP&#41; est&#225; relacionado directamente con el estadio de la enfermedad al diagn&#243;stico&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material y m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Realizamos TC de baja dosis &#40;TCBD&#41; a personas asintom&#225;ticas &#8805;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; fumadores o exfumadores de &#8805;<span class="elsevierStyleHsp" style=""></span>10 paquetes-a&#241;o&#44; sin antecedentes oncol&#243;gicos&#46; Seguimos un algoritmo de evaluaci&#243;n seg&#250;n el tama&#241;o y la morfolog&#237;a de los n&#243;dulos&#46; En los CP diagnosticados se estableci&#243; el tratamiento adecuado y el seguimiento fue de 5<span class="elsevierStyleHsp" style=""></span>a&#241;os&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Estudiamos 4&#46;951 personas &#40;65&#44;4&#37; varones&#41; con una media de edad de 56&#44;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;26<span class="elsevierStyleHsp" style=""></span>a&#241;os&#59; 550 presentaron n&#243;dulos&#46; De 3&#46;891 n&#243;dulos detectados&#44; 692 &#40;19&#44;57&#37;&#41; fueron considerados positivos&#44; hallando 38 tumores &#40;36<span class="elsevierStyleHsp" style=""></span>CP&#41;&#46; En el estudio anual&#44; 224 sujetos mostraban alg&#250;n n&#243;dulo&#44; siendo 288 &#40;7&#44;91&#37;&#41; positivos &#40;13<span class="elsevierStyleHsp" style=""></span>CP&#41;&#46; En el 80&#37; el control se realiz&#243; con TCBD y se indic&#243; biopsia en el 5&#44;8&#37; &#40;basal&#41; y 7&#44;6&#37; &#40;anual&#41; de los n&#243;dulos positivos&#46; La prevalencia fue del 0&#44;89 y la incidencia del 0&#44;1&#37;&#46; La sensibilidad&#44; la especificidad&#44; el VPP y el VPN en el estudio basal fueron del 92&#44;31&#44; del 89&#44;54&#44; del 6&#44;55 y del 99&#44;93&#37;&#44; respectivamente&#44; y en el anual&#44; del 76&#44;92&#44; del 95&#44;7&#44; del 4&#44;52 y del 99&#44;94&#37;&#44; respectivamente&#46; Se detectaron 52 tumores &#40;49<span class="elsevierStyleHsp" style=""></span>CP&#41;&#44; 25 &#40;52&#44;08&#37;&#41; en estadio<span class="elsevierStyleHsp" style=""></span>I&#46; La supervivencia global de los CP fue del 58&#44;5&#37; a los 5<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; y la supervivencia c&#225;ncer espec&#237;fica&#44; del 67&#44;1&#37; &#40;75&#44;8&#37; en los pacientes quir&#250;rgicos&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La TCBD integrada en un programa elaborado de detecci&#243;n y evaluaci&#243;n de n&#243;dulos es una herramienta &#250;til para diagnosticar CP en estadio precoz&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusiones"
          ]
        ]
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The prognosis of lung cancer &#40;LC&#41; correlates directly with the stage of the disease at the time of diagnosis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Material and methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We performed low-dose CT &#40;LDCT&#41; in asymptomatic individuals &#8805;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>years old&#44; smokers or former smokers of &#8805;<span class="elsevierStyleHsp" style=""></span>10 pack-years&#44; with no history of cancer&#46; We followed an evaluation algorithm&#44; according to the size and morphology of the nodules&#46; The appropriate treatment for the LC diagnosis was given and patients were followed up for 5<span class="elsevierStyleHsp" style=""></span>years&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">We studied 4&#44;951 individuals &#40;65&#46;4&#37; males&#41; with an average age of 56&#46;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;26<span class="elsevierStyleHsp" style=""></span>years&#59; 550 presented nodules&#46; Of the 3&#44;891 nodules detected&#44; 692 &#40;19&#46;57&#37;&#41; were considered positive&#44; and 38 tumors &#40;36<span class="elsevierStyleHsp" style=""></span>LC&#41; were identified&#46; In the annual follow-up&#44; nodules were found in 224 subjects&#44; 288 &#40;7&#46;91&#37;&#41; of which were positive &#40;13<span class="elsevierStyleHsp" style=""></span>LC&#41;&#46; In 80&#37;&#44; the study was performed with LDCT&#44; and biopsy was indicated in 5&#46;8&#37; &#40;baseline&#41; and in 7&#46;6&#37; &#40;annual&#41; of the positive nodules&#46; Prevalence was 0&#46;89 and incidence was 0&#46;1&#37;&#46; The sensitivity&#44; specificity&#44; PPV and NPV in the baseline study were 92&#46;31&#44; 89&#46;54&#44; 6&#46;55 and 99&#46;93&#37;&#44; respectively&#44; and in the annual study&#44; they were 76&#46;92&#44; 95&#46;7&#44; 4&#46;52 and 99&#46;94&#37;&#44; respectively&#46; A total of 52 tumors were detected &#40;49<span class="elsevierStyleHsp" style=""></span>LC&#41;&#44; 25 &#40;52&#46;08&#37;&#41; in stage<span class="elsevierStyleHsp" style=""></span>I&#46; The 5-year overall survival rate for LC was 58&#46;5&#37; and cancer-specific survival was 67&#46;1&#37; &#40;75&#46;8&#37; in surgical patients&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">LDCT integrated into an elaborate nodule detection and evaluation program is a useful tool for diagnosing early-stage LC&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0030"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Conclusion"
          ]
        ]
      ]
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    "apendice" => array:1 [
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          0 => array:4 [
            "apendice" => "<p id="par0170" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Anexo A"
            "titulo" => "Material suplementario"
            "identificador" => "sec0050"
          ]
        ]
      ]
    ]
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        "descripcion" => array:1 [
          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Decisiones por individuos en el estudio basal&#46;</p>"
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        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
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          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Decisiones por individuos en el estudio anual&#46;</p>"
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            "detalle" => "Tabla "
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><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">Sexo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hombres&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;237 &#40;65&#44;4&#37;&#41;&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">Mujeres&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;714 &#40;34&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Edad&#44; a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50-60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;905 &#40;78&#44;87&#37;&#41;&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">61-70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">942 &#40;19&#44;02&#37;&#41;&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">&#62;<span class="elsevierStyleHsp" style=""></span>70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">104 &#40;2&#44;01&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">H&#225;bito tabaco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fumadores activos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;713 &#40;54&#44;8&#37;&#41;&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">Exfumadores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;238 &#40;45&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&#241;os-paquete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#44;53&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">Hombres&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#44;45&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">Mujeres&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#44;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antecedentes familiares CP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">933 &#40;18&#44;84&#37;&#41;&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">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;913 &#40;79&#44;04&#37;&#41;&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">No sabe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">105 &#40;2&#44;12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Contacto asbesto&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antecedentes respiratorios&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">159 &#40;3&#44;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2141035.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas de la poblaci&#243;n de estudio</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Tabla 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
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        "tabla" => array:1 [
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Con diferenciaci&#243;n ent&#233;rica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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Article information
ISSN: 03002896
Original language: Spanish
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