Determination of a Low Risk Group for Having Metastatic Nodules Not Detected by Computed Tomography Scan in Lung Metastases Surgery

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=> "Zabaleta" "email" => array:1 [ 0 => "jon.zabaletajimenez@osakidetza.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Borja" "apellidos" => "Aguinagalde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "José Miguel" "apellidos" => "Izquierdo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Mikel" "apellidos" => "Mendoza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Francisco" "apellidos" => "Basterrechea" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Maialen" "apellidos" => "Martin-Arruti" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 6 => array:3 [ "nombre" => "Carmen" "apellidos" => "Lobo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 7 => array:3 [ "nombre" => "José Ignacio" "apellidos" => "Emparanza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía Torácica, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiología, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Epidemiología Clínica, CASPe y CIBER-ESP, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Determinación de grupo de bajo riesgo para tener nódulos metastásicos no detectados por tomografía axial computarizada en la cirugía de las metástasis pulmonares" ] ] "textoCompleto" => "IntroductionIn recent years, the resection of pulmonary metastases from primary extrapulmonary neoplasia has become an essential part of the activity of thoracic surgery departments.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Evidence from case series suggests that complete excision in selected patients results in greater survival than non-surgical treatments.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The goal in the treatment of pulmonary metastases is complete removal of the metastasis with minimal loss of lung parenchyma.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> Chest computed axial tomography (CT) is considered the test of choice before performing metastasectomy for determining the extension of the intrathoracic lesion.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> In recent years, there has been a debate in relation to the diagnostic accuracy of this procedure, and the need for lung palpation to determine the number of metastatic nodules present in the lung.<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a> A true reflection of the controversial nature of the subject is that in the book Difficult decisions in thoracic surgery: An evidence based approach, two chapters are dedicated to pulmonary metastasectomy,<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> with the authors concluding that:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-In relation to the need for palpation of both lungs,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> the absence of data showing improved survival after palpation of contralateral undetected nodules justifies unilateral access for nodules detected unilaterally.<a class="elsevierStyleCrossRef" href="#bib0030">6</a></li><li class="elsevierStyleListItem" id="lsti0010">-Comparing the videothorascopic (VATS) approach with thoracotomy<a class="elsevierStyleCrossRef" href="#bib0035">7</a>: (a) thoracotomy allows additional nodules to be identified in 20% of cases; (b) incomplete resection is considered therapeutic failure, but incomplete resection is not synonymous with the presence of a radiologically undetectable lesion post-VATS; (c) there is no scientific evidence to support that thoracotomy provides clinical improvement compared to VATS in terms of survival, and (d) the claim that thoracotomy has more advantages than VATS is supported solely by expert opinion. The available literature suggests that they are equivalent, and both approaches seem to be appropriate for resection of a solitary pulmonary metastasis.</li></ul>Determining the best form of approach is still under debate at present. In contrast to studies in which up to 20% of metastases not identified by CT scan were detected, which would have been missed by CT and VATS,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> there is an increasing number of scientific studies in which comparable survival and disease-free survival have been observed in patients who have undergone VATS compared to those who have undergone thoracotomy.<a class="elsevierStyleCrossRefs" href="#bib0025">5,9,10</a> Gossot et al.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> in patients with osteosarcoma metastases and Nakajima et al.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> and Nakaset et al.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> in subjects with metastases of colorectal origin, showed comparable survival and disease-free survival in patients who had undergone surgery by VATS compared to those who had undergone surgery by thoracotomy. The improvement in imaging tests in recent years is resulting in an improvement in the precision of CT, as we can see in the article published in 2008 by Kang et al.,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> in which the accuracy of CT reached 96% in metastases of colorectal origin.MethodsPatients who underwent surgery for pulmonary metastasis with curative intent between 1 January 1998 and 30 June 2012 were studied. During this period, 229 operations were carried out, 12 of which were performed using VATS, and therefore excluded from the study. Patients enrolled underwent thoracotomy and unilateral palpation to resect all the nodules palpated. The following were considered criteria for surgery: controlled primary tumour (or with a possibility of controlling it), absence of extrapulmonary metastases (except for resectable liver metastases), the patient was sufficiently healthy to tolerate the surgery (with good lung function tests) and with technically resectable metastases.SurgeryAll patients were operated on by the Thoracic Surgery Department of Hospital Universitario Donostia under general anaesthetic, single lung ventilation and posterolateral thoracotomy. As part of the pre-operative study, all patients underwent lung function tests (spirometry and diffusion), fibrobronchoscopy and CT. PET-CT was also performed on all patients from 2006 onwards. The procedure followed for the surgery was always the same: (a) examination of the parietal and visceral pleura; (b) release of pleuropulmonary adhesions (if any); (c) identification of pulmonary nodule(s), and (d) when the nodule was peripheral: intra-operative biopsy with atypical resection. If the intra-operative biopsy confirmed metastasis, no more lung was resected. If the pathologist was unable to determine whether the nature of the lesion was metastatic or a primary lung tumour, lobectomy with lymphadenectomy was then performed. In cases in which the tumour was central and did not permit intraoperative biopsy, lobectomy was carried out directly. Lymphadenectomy was performed in patients with metastasis and suspected mediastinal lymph node involvement.Preoperative StudyAll cases were reviewed preoperatively by 2 radiologists specialising in lung disease. A non-multislice one coronal helical CT (Siemens) with 5mm slices was performed on patients who underwent surgery before November 2002 and a non-multislice two coronal helical CT (Siemens Somatom Volume Access) with 5mm slices and contrast was performed on patients who underwent surgery after this date. All patients underwent surgery within 40 days of the CT scan.Statistical AnalysisThe objective was to compare the number of metastases identified by CT with the number of metastases resected per patient (histologically confirmed) after manual palpation, so benign nodules palpated and resected during the surgery were not taken into account. Systat version 13 was used for the statistical analysis. Quantitative variables were described using the interval, median and mean, and the qualitative variables using absolute and relative frequencies in percentage. Differences between both groups were measured using Fisher's exact test or the Chi-squared test for categorical variables and the Mann–Whitney test for quantitative variables.The study was approved by the Clinical Research Ethics Committee, as stated in Act no. 02/2012, having obtained informed consent from the patients.ResultsOne hundred and eighty-three (183) patients (63.6% males) were considered for the study, in whom 217 surgeries were carried out. The mean age was 61.7 years (median, 63; range, 24–82). Comparing the nodules detected in the CT scan with those resected in the surgery, the CT was accurate in 185 cases (85.3%). Among the discrepancies observed were: 26 patients (11.9%) with more metastases resected than observed and 6 cases (2.8%) with fewer metastases than observed. The main descriptive study variables are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Analysis According to SizeA total of 299 metastases were resected and their size analysed. Those diagnosed by CT had a mean size of 2.4cm (median, 2.0cm; range, 0.4–8cm) while those not observed had a mean size of 0.6cm (median, 0.5cm; range, 0.2–1cm). Statistically significant differences were observed when the two means were compared (P<.001). Tumours measuring less than 1cm were underdiagnosed in 19.4% of cases, tumours between 1 and 2cm in 12.8% and tumours over 2cm in 8.4%. The differences were not statistically significant (P=.213), although it was observed that the smaller the diameter, the higher the probability of not detecting any metastases.Analysis According to the Number of Metastases Observed in the Computed Axial TomographyA single nodule was seen in 176 cases, of which the assessment was correct in 158 cases (89.8%); 2 nodules were resected in 16 patients (9.1%) and 3 nodules in 2 patients (1.7%).Two nodules were found in 29 patients, with an accuracy of 72.4% (20 patients); there was only one metastatic tumour in 3 patients (10.3%), and in 5 patients (17.2%) more metastases were detected in the tissue specimen than were observed.Three nodules were observed in 10 patients; in 5 patients the assessment was correct (50.0%); in 2 cases (20.0%) fewer were seen, and in 3 cases (30.0%) more nodules appeared.Four nodules were seen on 2 occasions: 3 nodules were resected in the specimen in one (50.0%) and 4 nodules in the other (50.0%).Comparing the accuracy of the CT when one metastasis was observed (89.8%) against the accuracy when it said that there were more (65.8%), there were statistically significant differences (P<.001). However, on comparing the number of patients in whom a metastasis was missed, it was observed that in patients in whom the CT said that there was one, more tumours were resected than observed in 10.0% of patients, compared to 19.0% (P=.099) when more than one was observed on the CT, which means that when the CT says that there is a single metastasis, it has a Cohen kappa of 0.72, which represents substantial agreement between the data observed by CT and resected after surgery.Analysis According to HistologyThe most commonly found histology was intestinal adenocarcinoma (111 patients who underwent 123 procedures). Twenty-three surgeries were performed in patients with tumours of urogenital origin and 29 sarcomas. Metastases were underdiagnosed in 8.9% of colorectal cancers, 13.8% of sarcomas, 21.7% of urogenital tumours and in 14.3% of other origins. Comparing the different groups, although there was a greater tendency for metastases to be missed in the group of urogenital origin, no statistically significant differences were observed (P=.327).Grouping patients of colorectal origin with one or 2 metastases and single metastasis of any origin, the probability of resecting additional nodules was 9.5%. Comparing this with the rest, where the probability was 27.8%, statistically significant differences were observed (P=.001).Other VariablesOther variables were analysed, such as age, observing that the mean age of patients in whom unobserved nodules did not appear was 62.9 years, compared to a mean of 56.5 years in patients in whom a metastasis was missed (P=.001). No statistically significant differences were observed in relation to the disease-free interval, performance of a previous thoracotomy, sex, date or type of surgery (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Adding the variable of age, patients can be divided into 2 large groups. (1) Group with a low probability of detecting extra metastases: patients over 60 years of age, with one or 2 metastases of colorectal origin or one of any other origin, where metastasis was missed in only 4.4% of patients. (2) Group with a high probability of detecting extra metastases: patients under 60 years of age, with more than 2 metastases of colorectal origin or more than one of any other origin (20.4% of patients with more metastases resected than observed, P<.001).DiscussionThe role of VATS for resecting pulmonary metastases is controversial,<a class="elsevierStyleCrossRefs" href="#bib0035">7,13,14</a> as the advantages of VATS are set against its major drawback: the inability to palpate the lung. Among the advantages are: excellent visualisation of the pleural surface,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> smaller immune response to surgical stress,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> reduction in post-operative pain,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> shorter hospital stay<a class="elsevierStyleCrossRef" href="#bib0075">15</a> and post-operative recovery with fewer complications than in thoracotomy.<a class="elsevierStyleCrossRefs" href="#bib0050">10,16,17</a> Furthermore, since up to 50% of patients undergoing surgery for pulmonary metastases will present new pulmonary nodules,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> and since VATS causes fewer pleuropulmonary adhesions, it may favour repeat surgery in patients with recurrence.<a class="elsevierStyleCrossRefs" href="#bib0050">10,12,18</a> On the contrary, the importance of not being able to palpate the lung is that we can find numerous publications in which around 20% of previously undiagnosed metastases were detected.<a class="elsevierStyleCrossRefs" href="#bib0020">4,8,19–21</a>In our initial experience with VATS for pulmonary metastasis, we observed overall and disease-free survival comparable to that of patients who had undergone thoracotomy and the same rate of pulmonary recurrence.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> These results agree with the study published by Nakas et al.,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> who compared 25 patients who underwent thoracotomy with 27 VATS patients. They did not observe any statistically significant differences in survival, recurrence and recurrence in the same lung. Later, Nakajima et al.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> would reproduce the same results in patients with metastases of colorectal origin and Gossot et al.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> in patients with sarcomatous metastases. Therefore, we consider that VATS may be a therapeutic option in selected patients,<a class="elsevierStyleCrossRef" href="#bib0115">23</a> and that to try to minimise the negative effect of the absence of lung palpation, it would be interesting to study the possibility of grouping patients by the probability of having nodules not detectable by CT.According to results from the International Registry of Lung Metastases,<a class="elsevierStyleCrossRef" href="#bib0120">24</a> the accuracy of CT for detecting the exact number of pulmonary nodules was 61%. With these findings, they concluded that manual bilateral palpation was necessary for the final staging and to be able to resect all the metastases.In 2007, Parsons et al.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> published the results observed after operating on 60 patients with single lung metastases on CT; bilateral palpation was performed on all patients, finding 23% of patients with metastases in the supposedly healthy hemithorax. Thus they concluded, like the registry, that bilateral palpation was obligatory in metastasectomy. Similarly, Roth et al.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> compared the results of patients who had undergone sternotomy (which allows both lungs to be palpated with a single incision) with thoracotomy, where bilateral metastases not detected by CT were detected in patients who underwent sternotomy. However, on analysing the survival in both groups, no differences were observed when they were compared.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> Later, Younes et al.,<a class="elsevierStyleCrossRef" href="#bib0130">26</a> in the same research line, determined that most patients with unilateral lung metastases detected by CT had unilateral disease, and that delaying the contralateral thoracotomy until the lesions became visible by CT did not affect survival.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> For these reasons, Patel and DeCamp<a class="elsevierStyleCrossRef" href="#bib0030">6</a> concluded in their review that the absence of data showing improved survival after palpation of contralateral undetected nodules justifies unilateral access for nodules detected unilaterally.In 2008, a survey of members of the European Society of Chest Surgery was published,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> in which 98% of surgeons surveyed answered that they treated only one hemithorax in cases of single lung involvement detected by CT. From the same survey,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> it appears palpation is considered necessary by 65% of surgeons, i.e. they consider it unacceptable that up to 20% of metastases could be missed if minimally invasive surgery is performed. For this reason, it is particularly interesting to define the group of patients in which CT is most accurate, as they would be ideal candidates for VATS.In most studies to determine the accuracy of CT, nodules identified by CT were compared with those resected<a class="elsevierStyleCrossRefs" href="#bib0020">4,8,12,20,21</a>; these latter could be either metastatic or benign (around 30%–40% of the extra nodules resected were benign<a class="elsevierStyleCrossRefs" href="#bib0040">8,19,20</a>). To facilitate the statistical analysis in our study, only metastases not detected by CT were analysed, as the presence of non-resected benign nodules does not represent a decline in survival.In our study, unobserved metastases were resected in 26 patients (11.9%). Parsons et al.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> found that 46% of patients had nodules that were not detected previously. Analysing the characteristics of the patients included in their series in detail, it is notable that most of the patients who underwent surgery had metastases of sarcomatous origin. Chun et al.,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> in contrast, after reviewing 120 patients with tumours of colorectal origin, detected unidentified metastases in 25% of patients. Cerfolio et al.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> and Kang et al.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> found differences when comparing patients with metastases of colorectal origin with those of sarcomatous origin: patients with sarcomas had more undetected metastases, and in the non-sarcomatous group, the CT obtained a negative predictive value of 96% and a sensitivity of 97%.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> Similarly, in the study by Chun et al.,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> the sensitivity of CT in patients with a single metastasis of colorectal origin was 95%.The value of PET has been analysed to try to improve the pre-operative diagnosis. This can provide information on infiltration of mediastinal lymph nodes<a class="elsevierStyleCrossRef" href="#bib0015">3</a> and for detecting extrapulmonary disease,<a class="elsevierStyleCrossRef" href="#bib0145">29</a> but it does not aid in the detection of extrapulmonary nodules, since the sensitivity of PET for detecting nodules smaller than 10mm is 30%.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>According to the results obtained in our study, in the group with a low probability of detecting extra metastases (patient over 60 years of age with one or 2 metastases of colorectal origin or one of any other origin), metastasis was missed in only 4.4% of patients. These would be the ideal candidates for treatment using minimally invasive surgery, since they would benefit from its advantages, reducing as far as possible the harmful effect that not resecting all the metastases would have. On the contrary, a group with a high probability of detecting extra metastases would be patients under 60 years of age with more than 2 metastases of colorectal origin or more than one of any other origin (20.4% of patients with more metastases resected than observed). In deciding the procedure in this group, both surgeon and patient must discuss the pros and cons of each approach, knowing the advantages and limitations of each technique.ConclusionsThe group considered to have a low probability of resecting more metastases than observed were patients older than 60 years with one or 2 metastases of colorectal origin or one of any other origin.The group with a low probability of resecting more metastases than observed are ideal candidates for video thoracoscopic surgery. In the remaining patients, the probability that a metastasis would be missed and the benefits of VATS compared to thoracotomy would have to be assessed more carefully.Study LimitationsThe main study limitation is that this is a retrospective study, so that the conclusions derived from it must be considered as a starting point for future prospective studies.Authors’ ContributionsJZ: design, writing of the first draft and the final manuscript; BA: literature review and collaboration in writing the first draft; JI: data collection, review of the manuscript; MM: preoperative imaging study, review of the manuscript; FB: preoperative imaging study; MM: data collection; CL: pathology study; JE: statistical analysis, review of the manuscript.FundingThis study did not receive funding of any type.Conflict of InterestsThe authors declare that they have no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres296099" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec279772" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres296098" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec279773" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgery" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Preoperative Study" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical Analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Analysis According to Size" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Analysis According to the Number of Metastases Observed in the Computed Axial Tomography" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Analysis According to Histology" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Other Variables" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0060" "titulo" => "Conclusions" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Study Limitations" ] ] ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Authors’ Contributions" ] 10 => array:2 [ "identificador" => "sec0075" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflict of Interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-03-21" "fechaAceptado" => "2013-05-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec279772" "palabras" => array:5 [ 0 => "Lung metastases" 1 => "Lung metastasectomy" 2 => "Computed tomography scan" 3 => "Thoracotomy" 4 => "Thoracic surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec279773" "palabras" => array:5 [ 0 => "Metástasis pulmonar" 1 => "Metastasectomía pulmonar" 2 => "Tomografía axial computarizada" 3 => "Toracotomía" 4 => "Cirugía torácica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "IntroductionIn recent years, there has been debate regarding the diagnostic accuracy of computed tomography (CT) in the identification of lung metastases and the need for lung palpation to determine the number of metastatic nodules. The aim of this study was to determine in which patients the CT scan was more effective in detecting all metastases. MethodsWe studied all patients who underwent curative thoracotomy for pulmonary metastasis between 1998 and 2012. All cases were reviewed by two expert pulmonary radiologists before surgery. Statistical analyses were performed using Systat version 13. ResultsThe study included 183 patients (63.6% male) with a mean age of 61.7 years who underwent 217 interventions. The CT scan was correct in 185 cases (85.3%). Discrepancies observed: 26 patients (11.9%) with more metastases resected than observed and 6 cases (2.8%) with fewer metastases. In patients with one or two metastases of colorectal origin or a single metastasis of any other origin, the probability of finding extra nodules was 9.5%. In the remaining patients, the probability was 27.8%, with statistically significant differences (P=.001). The mean age of the patients in whom no unobserved nodules were detected was 62.9 years compared to 56.5 years on average in patients who were free from any metastases (P=.001). ConclusionsPatients older than 60 years, with one or two metastases of colorectal origin or a single metastasis from any other origin were considered to be the group with low probability of having more metastases resected than observed." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "IntroducciónEn los últimos años existe un debate en relación con la exactitud diagnóstica de la tomografía axial computarizada (TAC) para identificar metástasis pulmonares y la necesidad de la palpación pulmonar para determinar el número de nódulos metastásicos. El objetivo del estudio fue determinar en qué pacientes era más eficaz la TAC para detectar todas las metástasis. MétodosSe estudiaron todos los pacientes operados de metástasis pulmonar con intención curativa a través de toracotomía entre 1998 y 2012. Todos los casos fueron revisados preoperatoriamente por 2radiólogos expertos en pulmón. Para el análisis estadístico se utilizó el programa Systat versión 13. ResultadosCiento ochenta y tres pacientes (63,6% varones) con una edad media de 61,7años a los que se les realizaron 217 intervenciones. La TAC acertó en 185 casos (85,3%). Discordancias observadas: 26 pacientes (11,9%) con más metástasis resecadas que las observadas y 6 casos (2,8%) con menos metástasis. Agrupando a los pacientes de origen colorrectal con una o 2 metástasis y metástasis única de cualquier origen, la probabilidad de resecar nódulos extras fue del 9,5%. En el resto la probabilidad fue del 27,8%, observándose diferencias estadísticamente significativas (p=0,001). La edad media de los pacientes en los que no aparecieron nódulos no observados fue de 62,9años, frente a 56,5años de media en los pacientes que se escapaba alguna metástasis (p=0,001). ConclusionesSe consideró grupo con baja probabilidad de resecar más metástasis que las observadas a los pacientes mayores de 60años con una o 2metástasis de origen colorrectal o una de otro origen." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Zabaleta J, Aguinagalde B, Izquierdo JM, Mendoza M, Basterrechea F, Martin-Arruti M, et al. Determinación de grupo de bajo riesgo para tener nódulos metastásicos no detectados por tomografía axial computarizada en la cirugía de las metástasis pulmonares. Arch Bronconeumol. 2013;49:518–522." ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Nodules resected \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patients, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Nodules diagnosed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patients, n (%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">161 (74.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">176 (81.1%) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 (17.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (13.4%) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (5.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (4.6%) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (1.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (0.5%) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (1.4%) \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab431808.png" ] ] 1 => 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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Origin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patients, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Resection performed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patients, n (%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Colorectal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">123 (56.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atypical resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">128 (58.9%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sarcoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (13.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lobectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 (32.7%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kidney \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (6.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilobectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.5%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bladder \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (4.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pneumonectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (2.8%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Breast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (3.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lobectomy+atypical resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (3.2%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 (16.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (1.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab431807.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Main Descriptive Variables of the Study." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "DFI, disease free interval.One coronal CT was used up to November 2012, after which a 2 coronal CT was used (both with 5mm slices)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Percentage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Significance, P \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous thoracotomy</td></tr><tr title="table-row"><td class="td" title="\n \t\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 (196 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.724 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes (21 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.3% \t\t\t\t\t\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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male (138 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.000 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female (79 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.4% \t\t\t\t\t\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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DFI</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><12 months (48 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.615 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>12 months (168 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.3% \t\t\t\t\t\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"> \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><36 months (125 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.677 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>36 months (91 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.2% \t\t\t\t\t\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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of surgery</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atypical (128 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.530 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other (89 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.1% \t\t\t\t\t\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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Date of surgery</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Up to November 2002 (57 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.834 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">After November 2002 (160 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.3% \t\t\t\t\t\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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab431806.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patients in Whom More Metastases Were Resected Than Observed by CT." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cirugía de las metástasis pulmonares" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. 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Original Article

Determination of a Low Risk Group for Having Metastatic Nodules Not Detected by Computed Tomography Scan in Lung Metastases Surgery

Determinación de grupo de bajo riesgo para tener nódulos metastásicos no detectados por tomografía axial computarizada en la cirugía de las metástasis pulmonares

Jon Zabaletaa,

Corresponding author

jon.zabaletajimenez@osakidetza.net

Corresponding author.

, Borja Aguinagaldea, José Miguel Izquierdoa, Mikel Mendozab, Francisco Basterrecheab, Maialen Martin-Arrutic, Carmen Loboc, José Ignacio Emparanzad

a Servicio de Cirugía Torácica, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain

b Servicio de Radiología, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain

c Servicio de Anatomía Patológica, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain

d Departamento de Epidemiología Clínica, CASPe y CIBER-ESP, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain

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      "es" => array:1 [
        "titulo" => "Determinaci&#243;n de grupo de bajo riesgo para tener n&#243;dulos metast&#225;sicos no detectados por tomograf&#237;a axial computarizada en la cirug&#237;a de las met&#225;stasis pulmonares"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years&#44; the resection of pulmonary metastases from primary extrapulmonary neoplasia has become an essential part of the activity of thoracic surgery departments&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Evidence from case series suggests that complete excision in selected patients results in greater survival than non-surgical treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The goal in the treatment of pulmonary metastases is complete removal of the metastasis with minimal loss of lung parenchyma&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Chest computed axial tomography &#40;CT&#41; is considered the test of choice before performing metastasectomy for determining the extension of the intrathoracic lesion&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In recent years&#44; there has been a debate in relation to the diagnostic accuracy of this procedure&#44; and the need for lung palpation to determine the number of metastatic nodules present in the lung&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> A true reflection of the controversial nature of the subject is that in the book <span class="elsevierStyleItalic">Difficult decisions in thoracic surgery&#58; An evidence based approach</span>&#44; two chapters are dedicated to pulmonary metastasectomy&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> with the authors concluding that&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0010" class="elsevierStylePara elsevierViewall">In relation to the need for palpation of both lungs&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the absence of data showing improved survival after palpation of contralateral undetected nodules justifies unilateral access for nodules detected unilaterally&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0015" class="elsevierStylePara elsevierViewall">Comparing the videothorascopic &#40;VATS&#41; approach with thoracotomy<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#58; &#40;a&#41; thoracotomy allows additional nodules to be identified in 20&#37; of cases&#59; &#40;b&#41; incomplete resection is considered therapeutic failure&#44; but incomplete resection is not synonymous with the presence of a radiologically undetectable lesion post-VATS&#59; &#40;c&#41; there is no scientific evidence to support that thoracotomy provides clinical improvement compared to VATS in terms of survival&#44; and &#40;d&#41; the claim that thoracotomy has more advantages than VATS is supported solely by expert opinion&#46; The available literature suggests that they are equivalent&#44; and both approaches seem to be appropriate for resection of a solitary pulmonary metastasis&#46;</p></li></ul></p><p id="par0020" class="elsevierStylePara elsevierViewall">Determining the best form of approach is still under debate at present&#46; In contrast to studies in which up to 20&#37; of metastases not identified by CT scan were detected&#44; which would have been missed by CT and VATS&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> there is an increasing number of scientific studies in which comparable survival and disease-free survival have been observed in patients who have undergone VATS compared to those who have undergone thoracotomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9&#44;10</span></a> Gossot et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in patients with osteosarcoma metastases and Nakajima et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and Nakaset et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> in subjects with metastases of colorectal origin&#44; showed comparable survival and disease-free survival in patients who had undergone surgery by VATS compared to those who had undergone surgery by thoracotomy&#46; The improvement in imaging tests in recent years is resulting in an improvement in the precision of CT&#44; as we can see in the article published in 2008 by Kang et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> in which the accuracy of CT reached 96&#37; in metastases of colorectal origin&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Patients who underwent surgery for pulmonary metastasis with curative intent between 1 January 1998 and 30 June 2012 were studied&#46; During this period&#44; 229 operations were carried out&#44; 12 of which were performed using VATS&#44; and therefore excluded from the study&#46; Patients enrolled underwent thoracotomy and unilateral palpation to resect all the nodules palpated&#46; The following were considered criteria for surgery&#58; controlled primary tumour &#40;or with a possibility of controlling it&#41;&#44; absence of extrapulmonary metastases &#40;except for resectable liver metastases&#41;&#44; the patient was sufficiently healthy to tolerate the surgery &#40;with good lung function tests&#41; and with technically resectable metastases&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgery</span><p id="par0030" class="elsevierStylePara elsevierViewall">All patients were operated on by the Thoracic Surgery Department of Hospital Universitario Donostia under general anaesthetic&#44; single lung ventilation and posterolateral thoracotomy&#46; As part of the pre-operative study&#44; all patients underwent lung function tests &#40;spirometry and diffusion&#41;&#44; fibrobronchoscopy and CT&#46; PET-CT was also performed on all patients from 2006 onwards&#46; The procedure followed for the surgery was always the same&#58; &#40;a&#41; examination of the parietal and visceral pleura&#59; &#40;b&#41; release of pleuropulmonary adhesions &#40;if any&#41;&#59; &#40;c&#41; identification of pulmonary nodule&#40;s&#41;&#44; and &#40;d&#41; when the nodule was peripheral&#58; intra-operative biopsy with atypical resection&#46; If the intra-operative biopsy confirmed metastasis&#44; no more lung was resected&#46; If the pathologist was unable to determine whether the nature of the lesion was metastatic or a primary lung tumour&#44; lobectomy with lymphadenectomy was then performed&#46; In cases in which the tumour was central and did not permit intraoperative biopsy&#44; lobectomy was carried out directly&#46; Lymphadenectomy was performed in patients with metastasis and suspected mediastinal lymph node involvement&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Preoperative Study</span><p id="par0035" class="elsevierStylePara elsevierViewall">All cases were reviewed preoperatively by 2 radiologists specialising in lung disease&#46; A non-multislice one coronal helical CT &#40;Siemens&#41; with 5<span class="elsevierStyleHsp" style=""></span>mm slices was performed on patients who underwent surgery before November 2002 and a non-multislice two coronal helical CT &#40;Siemens Somatom Volume Access&#41; with 5<span class="elsevierStyleHsp" style=""></span>mm slices and contrast was performed on patients who underwent surgery after this date&#46; All patients underwent surgery within 40 days of the CT scan&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical Analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">The objective was to compare the number of metastases identified by CT with the number of metastases resected per patient &#40;histologically confirmed&#41; after manual palpation&#44; so benign nodules palpated and resected during the surgery were not taken into account&#46; Systat version 13 was used for the statistical analysis&#46; Quantitative variables were described using the interval&#44; median and mean&#44; and the qualitative variables using absolute and relative frequencies in percentage&#46; Differences between both groups were measured using Fisher&#39;s exact test or the Chi-squared test for categorical variables and the Mann&#8211;Whitney test for quantitative variables&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The study was approved by the Clinical Research Ethics Committee&#44; as stated in Act no&#46; 02&#47;2012&#44; having obtained informed consent from the patients&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">One hundred and eighty-three &#40;183&#41; patients &#40;63&#46;6&#37; males&#41; were considered for the study&#44; in whom 217 surgeries were carried out&#46; The mean age was 61&#46;7 years &#40;median&#44; 63&#59; range&#44; 24&#8211;82&#41;&#46; Comparing the nodules detected in the CT scan with those resected in the surgery&#44; the CT was accurate in 185 cases &#40;85&#46;3&#37;&#41;&#46; Among the discrepancies observed were&#58; 26 patients &#40;11&#46;9&#37;&#41; with more metastases resected than observed and 6 cases &#40;2&#46;8&#37;&#41; with fewer metastases than observed&#46; The main descriptive study variables are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Analysis According to Size</span><p id="par0055" class="elsevierStylePara elsevierViewall">A total of 299 metastases were resected and their size analysed&#46; Those diagnosed by CT had a mean size of 2&#46;4<span class="elsevierStyleHsp" style=""></span>cm &#40;median&#44; 2&#46;0<span class="elsevierStyleHsp" style=""></span>cm&#59; range&#44; 0&#46;4&#8211;8<span class="elsevierStyleHsp" style=""></span>cm&#41; while those not observed had a mean size of 0&#46;6<span class="elsevierStyleHsp" style=""></span>cm &#40;median&#44; 0&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#59; range&#44; 0&#46;2&#8211;1<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46; Statistically significant differences were observed when the two means were compared &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46; Tumours measuring less than 1<span class="elsevierStyleHsp" style=""></span>cm were underdiagnosed in 19&#46;4&#37; of cases&#44; tumours between 1 and 2<span class="elsevierStyleHsp" style=""></span>cm in 12&#46;8&#37; and tumours over 2<span class="elsevierStyleHsp" style=""></span>cm in 8&#46;4&#37;&#46; The differences were not statistically significant &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;213&#41;&#44; although it was observed that the smaller the diameter&#44; the higher the probability of not detecting any metastases&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Analysis According to the Number of Metastases Observed in the Computed Axial Tomography</span><p id="par0060" class="elsevierStylePara elsevierViewall">A single nodule was seen in 176 cases&#44; of which the assessment was correct in 158 cases &#40;89&#46;8&#37;&#41;&#59; 2 nodules were resected in 16 patients &#40;9&#46;1&#37;&#41; and 3 nodules in 2 patients &#40;1&#46;7&#37;&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Two nodules were found in 29 patients&#44; with an accuracy of 72&#46;4&#37; &#40;20 patients&#41;&#59; there was only one metastatic tumour in 3 patients &#40;10&#46;3&#37;&#41;&#44; and in 5 patients &#40;17&#46;2&#37;&#41; more metastases were detected in the tissue specimen than were observed&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Three nodules were observed in 10 patients&#59; in 5 patients the assessment was correct &#40;50&#46;0&#37;&#41;&#59; in 2 cases &#40;20&#46;0&#37;&#41; fewer were seen&#44; and in 3 cases &#40;30&#46;0&#37;&#41; more nodules appeared&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Four nodules were seen on 2 occasions&#58; 3 nodules were resected in the specimen in one &#40;50&#46;0&#37;&#41; and 4 nodules in the other &#40;50&#46;0&#37;&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Comparing the accuracy of the CT when one metastasis was observed &#40;89&#46;8&#37;&#41; against the accuracy when it said that there were more &#40;65&#46;8&#37;&#41;&#44; there were statistically significant differences &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46; However&#44; on comparing the number of patients in whom a metastasis was missed&#44; it was observed that in patients in whom the CT said that there was one&#44; more tumours were resected than observed in 10&#46;0&#37; of patients&#44; compared to 19&#46;0&#37; &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;099&#41; when more than one was observed on the CT&#44; which means that when the CT says that there is a single metastasis&#44; it has a Cohen kappa of 0&#46;72&#44; which represents substantial agreement between the data observed by CT and resected after surgery&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Analysis According to Histology</span><p id="par0085" class="elsevierStylePara elsevierViewall">The most commonly found histology was intestinal adenocarcinoma &#40;111 patients who underwent 123 procedures&#41;&#46; Twenty-three surgeries were performed in patients with tumours of urogenital origin and 29 sarcomas&#46; Metastases were underdiagnosed in 8&#46;9&#37; of colorectal cancers&#44; 13&#46;8&#37; of sarcomas&#44; 21&#46;7&#37; of urogenital tumours and in 14&#46;3&#37; of other origins&#46; Comparing the different groups&#44; although there was a greater tendency for metastases to be missed in the group of urogenital origin&#44; no statistically significant differences were observed &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;327&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Grouping patients of colorectal origin with one or 2 metastases and single metastasis of any origin&#44; the probability of resecting additional nodules was 9&#46;5&#37;&#46; Comparing this with the rest&#44; where the probability was 27&#46;8&#37;&#44; statistically significant differences were observed &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Other Variables</span><p id="par0095" class="elsevierStylePara elsevierViewall">Other variables were analysed&#44; such as age&#44; observing that the mean age of patients in whom unobserved nodules did not appear was 62&#46;9 years&#44; compared to a mean of 56&#46;5 years in patients in whom a metastasis was missed &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41;&#46; No statistically significant differences were observed in relation to the disease-free interval&#44; performance of a previous thoracotomy&#44; sex&#44; date or type of surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Adding the variable of age&#44; patients can be divided into 2 large groups&#46; &#40;1&#41; Group with a low probability of detecting extra metastases&#58; patients over 60 years of age&#44; with one or 2 metastases of colorectal origin or one of any other origin&#44; where metastasis was missed in only 4&#46;4&#37; of patients&#46; &#40;2&#41; Group with a high probability of detecting extra metastases&#58; patients under 60 years of age&#44; with more than 2 metastases of colorectal origin or more than one of any other origin &#40;20&#46;4&#37; of patients with more metastases resected than observed&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The role of VATS for resecting pulmonary metastases is controversial&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;13&#44;14</span></a> as the advantages of VATS are set against its major drawback&#58; the inability to palpate the lung&#46; Among the advantages are&#58; excellent visualisation of the pleural surface&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> smaller immune response to surgical stress&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> reduction in post-operative pain&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> shorter hospital stay<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and post-operative recovery with fewer complications than in thoracotomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;16&#44;17</span></a> Furthermore&#44; since up to 50&#37; of patients undergoing surgery for pulmonary metastases will present new pulmonary nodules&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and since VATS causes fewer pleuropulmonary adhesions&#44; it may favour repeat surgery in patients with recurrence&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;12&#44;18</span></a> On the contrary&#44; the importance of not being able to palpate the lung is that we can find numerous publications in which around 20&#37; of previously undiagnosed metastases were detected&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8&#44;19&#8211;21</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In our initial experience with VATS for pulmonary metastasis&#44; we observed overall and disease-free survival comparable to that of patients who had undergone thoracotomy and the same rate of pulmonary recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> These results agree with the study published by Nakas et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> who compared 25 patients who underwent thoracotomy with 27 VATS patients&#46; They did not observe any statistically significant differences in survival&#44; recurrence and recurrence in the same lung&#46; Later&#44; Nakajima et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> would reproduce the same results in patients with metastases of colorectal origin and Gossot et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in patients with sarcomatous metastases&#46; Therefore&#44; we consider that VATS may be a therapeutic option in selected patients&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> and that to try to minimise the negative effect of the absence of lung palpation&#44; it would be interesting to study the possibility of grouping patients by the probability of having nodules not detectable by CT&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">According to results from the International Registry of Lung Metastases&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> the accuracy of CT for detecting the exact number of pulmonary nodules was 61&#37;&#46; With these findings&#44; they concluded that manual bilateral palpation was necessary for the final staging and to be able to resect all the metastases&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In 2007&#44; Parsons et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> published the results observed after operating on 60 patients with single lung metastases on CT&#59; bilateral palpation was performed on all patients&#44; finding 23&#37; of patients with metastases in the supposedly healthy hemithorax&#46; Thus they concluded&#44; like the registry&#44; that bilateral palpation was obligatory in metastasectomy&#46; Similarly&#44; Roth et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> compared the results of patients who had undergone sternotomy &#40;which allows both lungs to be palpated with a single incision&#41; with thoracotomy&#44; where bilateral metastases not detected by CT were detected in patients who underwent sternotomy&#46; However&#44; on analysing the survival in both groups&#44; no differences were observed when they were compared&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Later&#44; Younes et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> in the same research line&#44; determined that most patients with unilateral lung metastases detected by CT had unilateral disease&#44; and that delaying the contralateral thoracotomy until the lesions became visible by CT did not affect survival&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> For these reasons&#44; Patel and DeCamp<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> concluded in their review that the absence of data showing improved survival after palpation of contralateral undetected nodules justifies unilateral access for nodules detected unilaterally&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In 2008&#44; a survey of members of the European Society of Chest Surgery was published&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> in which 98&#37; of surgeons surveyed answered that they treated only one hemithorax in cases of single lung involvement detected by CT&#46; From the same survey&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> it appears palpation is considered necessary by 65&#37; of surgeons&#44; i&#46;e&#46; they consider it unacceptable that up to 20&#37; of metastases could be missed if minimally invasive surgery is performed&#46; For this reason&#44; it is particularly interesting to define the group of patients in which CT is most accurate&#44; as they would be ideal candidates for VATS&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In most studies to determine the accuracy of CT&#44; nodules identified by CT were compared with those resected<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8&#44;12&#44;20&#44;21</span></a>&#59; these latter could be either metastatic or benign &#40;around 30&#37;&#8211;40&#37; of the extra nodules resected were benign<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;19&#44;20</span></a>&#41;&#46; To facilitate the statistical analysis in our study&#44; only metastases not detected by CT were analysed&#44; as the presence of non-resected benign nodules does not represent a decline in survival&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In our study&#44; unobserved metastases were resected in 26 patients &#40;11&#46;9&#37;&#41;&#46; Parsons et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> found that 46&#37; of patients had nodules that were not detected previously&#46; Analysing the characteristics of the patients included in their series in detail&#44; it is notable that most of the patients who underwent surgery had metastases of sarcomatous origin&#46; Chun et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> in contrast&#44; after reviewing 120 patients with tumours of colorectal origin&#44; detected unidentified metastases in 25&#37; of patients&#46; Cerfolio et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> and Kang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> found differences when comparing patients with metastases of colorectal origin with those of sarcomatous origin&#58; patients with sarcomas had more undetected metastases&#44; and in the non-sarcomatous group&#44; the CT obtained a negative predictive value of 96&#37; and a sensitivity of 97&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Similarly&#44; in the study by Chun et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> the sensitivity of CT in patients with a single metastasis of colorectal origin was 95&#37;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The value of PET has been analysed to try to improve the pre-operative diagnosis&#46; This can provide information on infiltration of mediastinal lymph nodes<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and for detecting extrapulmonary disease&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> but it does not aid in the detection of extrapulmonary nodules&#44; since the sensitivity of PET for detecting nodules smaller than 10<span class="elsevierStyleHsp" style=""></span>mm is 30&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">According to the results obtained in our study&#44; in the group with a low probability of detecting extra metastases &#40;patient over 60 years of age with one or 2 metastases of colorectal origin or one of any other origin&#41;&#44; metastasis was missed in only 4&#46;4&#37; of patients&#46; These would be the ideal candidates for treatment using minimally invasive surgery&#44; since they would benefit from its advantages&#44; reducing as far as possible the harmful effect that not resecting all the metastases would have&#46; On the contrary&#44; a group with a high probability of detecting extra metastases would be patients under 60 years of age with more than 2 metastases of colorectal origin or more than one of any other origin &#40;20&#46;4&#37; of patients with more metastases resected than observed&#41;&#46; In deciding the procedure in this group&#44; both surgeon and patient must discuss the pros and cons of each approach&#44; knowing the advantages and limitations of each technique&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions</span><p id="par0150" class="elsevierStylePara elsevierViewall">The group considered to have a low probability of resecting more metastases than observed were patients older than 60 years with one or 2 metastases of colorectal origin or one of any other origin&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The group with a low probability of resecting more metastases than observed are ideal candidates for video thoracoscopic surgery&#46; In the remaining patients&#44; the probability that a metastasis would be missed and the benefits of VATS compared to thoracotomy would have to be assessed more carefully&#46;</p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Study Limitations</span><p id="par0160" class="elsevierStylePara elsevierViewall">The main study limitation is that this is a retrospective study&#44; so that the conclusions derived from it must be considered as a starting point for future prospective studies&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Authors&#8217; Contributions</span><p id="par0165" class="elsevierStylePara elsevierViewall">JZ&#58; design&#44; writing of the first draft and the final manuscript&#59; BA&#58; literature review and collaboration in writing the first draft&#59; JI&#58; data collection&#44; review of the manuscript&#59; MM&#58; preoperative imaging study&#44; review of the manuscript&#59; FB&#58; preoperative imaging study&#59; MM&#58; data collection&#59; CL&#58; pathology study&#59; JE&#58; statistical analysis&#44; review of the manuscript&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">This study did not receive funding of any type&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflict of Interests</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests&#46;</p></span></span>"
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          "identificador" => "xres296099"
          "titulo" => array:5 [
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        1 => array:2 [
          "identificador" => "xpalclavsec279772"
          "titulo" => "Keywords"
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          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Introducci&#243;n"
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          "titulo" => "Palabras clave"
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            0 => array:2 [
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              "titulo" => "Preoperative Study"
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              "titulo" => "Analysis According to Size"
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              "titulo" => "Analysis According to the Number of Metastases Observed in the Computed Axial Tomography"
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              "titulo" => "Analysis According to Histology"
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              "titulo" => "Other Variables"
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          "titulo" => "Discussion"
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              "titulo" => "Study Limitations"
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          "titulo" => "Authors&#8217; Contributions"
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          "titulo" => "Conflict of Interests"
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          "titulo" => "References"
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    "tienePdf" => true
    "fechaRecibido" => "2013-03-21"
    "fechaAceptado" => "2013-05-28"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec279772"
          "palabras" => array:5 [
            0 => "Lung metastases"
            1 => "Lung metastasectomy"
            2 => "Computed tomography scan"
            3 => "Thoracotomy"
            4 => "Thoracic surgery"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec279773"
          "palabras" => array:5 [
            0 => "Met&#225;stasis pulmonar"
            1 => "Metastasectom&#237;a pulmonar"
            2 => "Tomograf&#237;a axial computarizada"
            3 => "Toracotom&#237;a"
            4 => "Cirug&#237;a tor&#225;cica"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In recent years&#44; there has been debate regarding the diagnostic accuracy of computed tomography &#40;CT&#41; in the identification of lung metastases and the need for lung palpation to determine the number of metastatic nodules&#46; The aim of this study was to determine in which patients the CT scan was more effective in detecting all metastases&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We studied all patients who underwent curative thoracotomy for pulmonary metastasis between 1998 and 2012&#46; All cases were reviewed by two expert pulmonary radiologists before surgery&#46; Statistical analyses were performed using Systat version 13&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study included 183 patients &#40;63&#46;6&#37; male&#41; with a mean age of 61&#46;7 years who underwent 217 interventions&#46; The CT scan was correct in 185 cases &#40;85&#46;3&#37;&#41;&#46; Discrepancies observed&#58; 26 patients &#40;11&#46;9&#37;&#41; with more metastases resected than observed and 6 cases &#40;2&#46;8&#37;&#41; with fewer metastases&#46; In patients with one or two metastases of colorectal origin or a single metastasis of any other origin&#44; the probability of finding extra nodules was 9&#46;5&#37;&#46; In the remaining patients&#44; the probability was 27&#46;8&#37;&#44; with statistically significant differences &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41;&#46; The mean age of the patients in whom no unobserved nodules were detected was 62&#46;9 years compared to 56&#46;5 years on average in patients who were free from any metastases &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patients older than 60 years&#44; with one or two metastases of colorectal origin or a single metastasis from any other origin were considered to be the group with low probability of having more metastases resected than observed&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En los &#250;ltimos a&#241;os existe un debate en relaci&#243;n con la exactitud diagn&#243;stica de la tomograf&#237;a axial computarizada &#40;TAC&#41; para identificar met&#225;stasis pulmonares y la necesidad de la palpaci&#243;n pulmonar para determinar el n&#250;mero de n&#243;dulos metast&#225;sicos&#46; El objetivo del estudio fue determinar en qu&#233; pacientes era m&#225;s eficaz la TAC para detectar todas las met&#225;stasis&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se estudiaron todos los pacientes operados de met&#225;stasis pulmonar con intenci&#243;n curativa a trav&#233;s de toracotom&#237;a entre 1998 y 2012&#46; Todos los casos fueron revisados preoperatoriamente por 2<span class="elsevierStyleHsp" style=""></span>radi&#243;logos expertos en pulm&#243;n&#46; Para el an&#225;lisis estad&#237;stico se utiliz&#243; el programa Systat versi&#243;n 13&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ciento ochenta y tres pacientes &#40;63&#44;6&#37; varones&#41; con una edad media de 61&#44;7<span class="elsevierStyleHsp" style=""></span>a&#241;os a los que se les realizaron 217 intervenciones&#46; La TAC acert&#243; en 185 casos &#40;85&#44;3&#37;&#41;&#46; Discordancias observadas&#58; 26 pacientes &#40;11&#44;9&#37;&#41; con m&#225;s met&#225;stasis resecadas que las observadas y 6 casos &#40;2&#44;8&#37;&#41; con menos met&#225;stasis&#46; Agrupando a los pacientes de origen colorrectal con una o 2 met&#225;stasis y met&#225;stasis &#250;nica de cualquier origen&#44; la probabilidad de resecar n&#243;dulos extras fue del 9&#44;5&#37;&#46; En el resto la probabilidad fue del 27&#44;8&#37;&#44; observ&#225;ndose diferencias estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; La edad media de los pacientes en los que no aparecieron n&#243;dulos no observados fue de 62&#44;9<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; frente a 56&#44;5<span class="elsevierStyleHsp" style=""></span>a&#241;os de media en los pacientes que se escapaba alguna met&#225;stasis &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se consider&#243; grupo con baja probabilidad de resecar m&#225;s met&#225;stasis que las observadas a los pacientes mayores de 60<span class="elsevierStyleHsp" style=""></span>a&#241;os con una o 2<span class="elsevierStyleHsp" style=""></span>met&#225;stasis de origen colorrectal o una de otro origen&#46;</p>"
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    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Zabaleta J&#44; Aguinagalde B&#44; Izquierdo JM&#44; Mendoza M&#44; Basterrechea F&#44; Martin-Arruti M&#44; et al&#46; Determinaci&#243;n de grupo de bajo riesgo para tener n&#243;dulos metast&#225;sicos no detectados por tomograf&#237;a axial computarizada en la cirug&#237;a de las met&#225;stasis pulmonares&#46; Arch Bronconeumol&#46; 2013&#59;49&#58;518&#8211;522&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Patients&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Colorectal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">123 &#40;56&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atypical resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">128 &#40;58&#46;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sarcoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;13&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lobectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71 &#40;32&#46;7&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kidney&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;6&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bilobectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;5&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;4&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pneumonectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;2&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;3&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lobectomy&#43;atypical resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;3&#46;2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;16&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;1&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab431807.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Main Descriptive Variables of the Study&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">DFI&#44; disease free interval&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">One coronal CT was used up to November 2012&#44; after which a 2 coronal CT was used &#40;both with 5<span class="elsevierStyleHsp" style=""></span>mm slices&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Percentage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Significance&#44; <span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Previous thoracotomy</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No &#40;196 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;724&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes &#40;21 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male &#40;138 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;000&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female &#40;79 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">DFI</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;12 months &#40;48 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;615&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;12 months &#40;168 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;36 months &#40;125 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;677&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;36 months &#40;91 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Type of surgery</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Atypical &#40;128 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;530&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other &#40;89 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Date of surgery</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Up to November 2002 &#40;57 patients&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;834&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>After November 2002 &#40;160 patients&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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Article information

ISSN: 15792129
Original language: English

DOI:10.1016/j.arbr.2013.10.002

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Year/Month	Html	Pdf	Total

2024 November	4	2	6
2024 October	44	32	76
2024 September	40	11	51
2024 August	61	48	109
2024 July	47	20	67
2024 June	47	26	73
2024 May	75	26	101
2024 April	30	26	56
2024 March	40	16	56
2024 February	25	22	47
2023 March	7	2	9
2023 February	27	17	44
2023 January	18	29	47
2022 December	30	31	61
2022 November	49	27	76
2022 October	27	29	56
2022 September	20	38	58
2022 August	28	37	65
2022 July	27	41	68
2022 June	19	33	52
2022 May	29	27	56
2022 April	24	30	54
2022 March	43	45	88
2022 February	26	28	54
2022 January	22	34	56
2021 December	23	36	59
2021 November	33	43	76
2021 October	34	30	64
2021 September	29	43	72
2021 August	32	26	58
2021 July	27	27	54
2021 June	28	28	56
2021 May	32	42	74
2021 April	34	60	94
2021 March	38	26	64
2021 February	21	25	46
2021 January	24	6	30
2020 December	17	14	31
2020 November	22	16	38
2020 October	17	12	29
2020 September	20	11	31
2020 August	23	17	40
2020 July	17	18	35
2020 June	12	6	18
2020 May	26	12	38
2020 April	26	16	42
2020 March	22	13	35
2020 February	21	15	36
2020 January	32	22	54
2019 December	23	18	41
2019 November	16	19	35
2019 October	14	8	22
2019 September	21	8	29
2019 August	15	7	22
2019 July	21	33	54
2019 June	10	8	18
2019 May	29	7	36
2019 April	22	24	46
2019 March	36	17	53
2019 February	34	11	45
2019 January	24	11	35
2018 December	38	13	51
2018 November	48	26	74
2018 October	43	26	69
2018 September	17	6	23
2018 June	2	0	2
2018 May	12	0	12
2018 April	32	1	33
2018 March	10	5	15
2018 February	18	7	25
2018 January	24	6	30
2017 December	40	6	46
2017 November	33	8	41
2017 October	30	9	39
2017 September	35	5	40
2017 August	47	10	57
2017 July	38	6	44
2017 June	55	6	61
2017 May	42	9	51
2017 April	42	10	52
2017 March	34	33	67
2017 February	15	3	18
2017 January	22	9	31
2016 December	41	5	46
2016 November	37	7	44
2016 October	54	14	68
2016 September	54	17	71
2016 August	50	8	58
2016 July	30	9	39
2016 March	3	0	3
2015 December	2	0	2
2015 October	34	2	36
2015 September	39	4	43
2015 August	29	9	38
2015 July	30	4	34
2015 June	28	6	34
2015 May	37	8	45
2015 April	25	6	31
2015 March	33	4	37
2015 February	26	7	33
2015 January	18	6	24
2014 December	35	3	38
2014 November	12	5	17
2014 October	24	5	29
2014 September	27	6	33
2014 August	23	8	31
2014 July	18	6	24
2014 June	42	9	51
2014 May	36	10	46
2014 April	48	12	60
2014 March	47	18	65
2014 January	1	4	5
2013 December	0	2	2

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