Scientific Letter
Radiological Diagnosis of Pulmonary Tumor Thrombotic Microangiopathy: A Non-bronchial Cause of «Tree-in-Bud» Pattern on Computed Tomography
Diagnóstico radiológico de microangiopatía trombótica tumoral pulmonar: una causa no bronquial de patrón de «árbol en brote» en tomografía computarizada
Luis Gorospe Sarasúa
, Almudena Ureña-Vacas, Ernesto García-Santana
Corresponding author
Servicio de Radiodiagnóstico, Hospital Universitario Ramón y Cajal, Madrid, Spain
Read
6270
Timeswas read the article
2240
Total PDF
4030
Total HTML
Share statistics
array:24 [ "pii" => "S1579212916302221" "issn" => "15792129" "doi" => "10.1016/j.arbr.2016.04.013" "estado" => "S300" "fechaPublicacion" => "2016-12-01" "aid" => "1379" "copyright" => "SEPAR" "copyrightAnyo" => "2016" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2016;52:621-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2325 "formatos" => array:3 [ "EPUB" => 122 "HTML" => 1507 "PDF" => 696 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0300289616301004" "issn" => "03002896" "doi" => "10.1016/j.arbres.2016.04.010" "estado" => "S300" "fechaPublicacion" => "2016-12-01" "aid" => "1379" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2016;52:621-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3978 "formatos" => array:3 [ "EPUB" => 127 "HTML" => 3171 "PDF" => 680 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científica</span>" "titulo" => "Diagnóstico radiológico de microangiopatía trombótica tumoral pulmonar: una causa no bronquial de patrón de «árbol en brote» en tomografía computarizada" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "621" "paginaFinal" => "622" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Radiological diagnosis of pulmonary tumor thrombotic microangiopathy: A non-bronchial cause of «tree-in-bud» pattern on computed tomography" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 959 "Ancho" => 3252 "Tamanyo" => 367832 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Imagen axial de la TC de tórax (ventana de parénquima pulmonar) en la que se observa un engrosamiento lineal del intersticio pulmonar subpleural (flechas). B) Reconstrucción axial MIP (proyección de máxima intensidad, ventana de parénquima pulmonar) del pulmón izquierdo en la que se observa un patrón de «árbol en brote» periférico consistente en opacidades lineales que se ramifican de predominio subpleural (ver dicho patrón en el interior de las elipses). Nótese también la presencia de pequeños nódulos centrolobulillares (flecha). C) Reconstrucción coronal MIP (ventana de parénquima pulmonar) del pulmón izquierdo en la que también se observa el patrón de «árbol en brote» en el interior de la elipse. D) Imagen sagital de la TC de tórax (ventana de hueso) en la que se visualizan múltiples lesiones focales óseas de predominio escleroso (flechas) en esternón y en varios cuerpos vertebrales, compatibles con metástasis óseas.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luis Gorospe Sarasúa, Almudena Ureña-Vacas, Ernesto García-Santana" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Luis" "apellidos" => "Gorospe Sarasúa" ] 1 => array:2 [ "nombre" => "Almudena" "apellidos" => "Ureña-Vacas" ] 2 => array:2 [ "nombre" => "Ernesto" "apellidos" => "García-Santana" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1579212916302221" "doi" => "10.1016/j.arbr.2016.04.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212916302221?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289616301004?idApp=UINPBA00003Z" "url" => "/03002896/0000005200000012/v1_201611260110/S0300289616301004/v1_201611260110/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1579212916302270" "issn" => "15792129" "doi" => "10.1016/j.arbr.2016.05.018" "estado" => "S300" "fechaPublicacion" => "2016-12-01" "aid" => "1397" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2016;52:622-3" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1943 "formatos" => array:3 [ "EPUB" => 119 "HTML" => 1230 "PDF" => 594 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Efficacy of Double Bronchodilation (LABA+LAMA) in Patients with Chronic Obstructive Pulmonary Disease (COPD) and Lung Cancer" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "622" "paginaFinal" => "623" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis de la eficacia de la doble broncodilatación (LABA+LAMA) en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) y cáncer de pulmón" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Virginia Leiro-Fernández, Ana Priegue Carrera, Alberto Fernández-Villar" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Virginia" "apellidos" => "Leiro-Fernández" ] 1 => array:2 [ "nombre" => "Ana" "apellidos" => "Priegue Carrera" ] 2 => array:2 [ "nombre" => "Alberto" "apellidos" => "Fernández-Villar" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0300289616301685" "doi" => "10.1016/j.arbres.2016.05.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289616301685?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212916302270?idApp=UINPBA00003Z" "url" => "/15792129/0000005200000012/v1_201611260059/S1579212916302270/v1_201611260059/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1579212916302233" "issn" => "15792129" "doi" => "10.1016/j.arbr.2016.04.014" "estado" => "S300" "fechaPublicacion" => "2016-12-01" "aid" => "1380" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2016;52:619-21" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4683 "formatos" => array:3 [ "EPUB" => 166 "HTML" => 3866 "PDF" => 651 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "NUT Midline Carcinoma of the Lung, A Rare Form of Lung Cancer" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "619" "paginaFinal" => "621" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Carcinoma NUT pulmonar, una forma poco frecuente de cáncer de pulmón" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1350 "Ancho" => 1800 "Tamanyo" => 430772 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computed tomography images showing the pulmonary lesion in the right upper lobe, and images from the pathological examination showing undifferentiated tumor cells (A) and positive immunoreaction to NUT antibody (B).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Cristina Benito Bernáldez, Concepción Romero Muñoz, Virginia Almadana Pacheco" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Cristina" "apellidos" => "Benito Bernáldez" ] 1 => array:2 [ "nombre" => "Concepción" "apellidos" => "Romero Muñoz" ] 2 => array:2 [ "nombre" => "Virginia" "apellidos" => "Almadana Pacheco" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0300289616301016" "doi" => "10.1016/j.arbres.2016.04.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289616301016?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212916302233?idApp=UINPBA00003Z" "url" => "/15792129/0000005200000012/v1_201611260059/S1579212916302233/v1_201611260059/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Radiological Diagnosis of Pulmonary Tumor Thrombotic Microangiopathy: A Non-bronchial Cause of «Tree-in-Bud» Pattern on Computed Tomography" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "621" "paginaFinal" => "622" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Luis Gorospe Sarasúa, Almudena Ureña-Vacas, Ernesto García-Santana" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Luis" "apellidos" => "Gorospe Sarasúa" "email" => array:1 [ 0 => "luisgorospe@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Almudena" "apellidos" => "Ureña-Vacas" ] 2 => array:2 [ "nombre" => "Ernesto" "apellidos" => "García-Santana" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario Ramón y Cajal, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diagnóstico radiológico de microangiopatía trombótica tumoral pulmonar: una causa no bronquial de patrón de «árbol en brote» en tomografía computarizada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 610 "Ancho" => 2067 "Tamanyo" => 213985 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Axial image of chest CT (pulmonary parenchymal window) showing linear thickening of the subpleural lung interstitium (arrows). (B) Maximum intensity projection (MIP) axial reconstruction (pulmonary parenchymal window) of left lung, showing a peripheral “tree-in-bud” pattern consisting of linear opacities forming predominantly subpleural branches (circled). See also the presence of small centrilobular nodules (arrow). (C) MIP coronal reconstruction (pulmonary parenchymal window) of the left lung, also showing the “tree-in-bud” pattern (circled). (D) Chest CT sagittal image (bone window) revealing multiple focal bone lesions (arrows) in the sternum and several vertebrae, consistent with bone metastases.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare and generally fatal form of pulmonary tumor embolism that generally presents with rapidly progressing dyspnea in patients with disseminated malignant disease. Clinical diagnosis is difficult, and unfortunately PTTM is generally only confirmed <span class="elsevierStyleItalic">post mortem.</span><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 58-year-old man, former smoker (20 pack-years), who presented with a 2-week history of progressive dyspnea and dry cough. Significant clinical history included prostate adenocarcinoma (Gleason score 6), treated with radiation therapy with curative intent 6 years previously, with no biochemical evidence of tumor relapse. Clinical examination revealed tachypnea and fine crackles on auscultation. Basal oxygen saturation was 88% and laboratory test findings did not suggest infection, although D-dimer levels were elevated. A chest radiograph showed bilateral diffuse interstitial involvement and prominent lung hila. Chest CT angiogram ruled out embolism on the main pulmonary, lobar or segmentary arteries, although multiple mediastinal and hilar lymphadenopathies were detected, along with severe interstitial involvement consistent with thickening of the subpleural pulmonary interstitium (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) and the presence of numerous centrilobular nodules and “tree-in-bud” images (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B and <span class="elsevierStyleSmallCaps">C</span>). Multiple focal bone lesions, predominantly sclerotic, were also observed in the vertebrae and sternum, consistent with metastasis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). Given these radiological findings, PTTM secondary to prostate adenocarcinoma was suggested as an initial diagnosis, although other possibilities such as sarcoidosis or infection with an unusual pathogen were not ruled out. Four days after admission, the patient developed rapidly progressing respiratory failure that required urgent intubation. A few hours later, he suffered an episode of cardiorespiratory arrest with asystole and died despite prolonged attempts at cardiopulmonary resuscitation. The diagnosis of PTTM was confirmed on autopsy, which revealed an unsuspected undifferentiated occult gastric “signet ring” adenocarcinoma, with extensive metastases and multiple tumor embolisms in the small-caliber peripheral pulmonary arteries.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">PTTM is a rare form of pulmonary arterial tumor embolism, in which small tumor cell embolisms cause fibrocellular proliferation in the intima of small-caliber pulmonary arteries. These changes lead to stenosis/occlusion of the pulmonary arteries and a subsequent rise in pulmonary vascular resistance, which in turn leads to rapidly progressing precapillary pulmonary hypertension.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Clinically, patients tend to develop acute/subacute <span class="elsevierStyleItalic">cor pulmonale</span> and respiratory failure. Most patients who develop PTTM have documented metastatic cancer, the most common tumor being gastric adenocarcinoma followed by lung cancer, but on occasions (as in our case) it can occur in patients with no diagnosis of metastatic disease.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> In a recent review, none of the 30 cases scrutinized was due to disseminated prostate cancer.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Unfortunately, most PTTMs are diagnosed <span class="elsevierStyleItalic">post mortem</span> on autopsy, and only some isolated cases have been described in surgical biopsies <span class="elsevierStyleItalic">ante mortem.</span> Only a high clinical suspicion and consistent radiological findings will prompt the physician to make a clinical diagnosis of PTTM and to plan the appropriate treatment, which is generally based on a combination of chemotherapy, anti-coagulants and corticosteroids.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Significant radiological signs of PTTM described on CT include the “tree-in-bud” pattern. This is practically the only vascular cause of this radiological pattern, and should be distinguished from the bronchial presentation that is generally observed in patients with infectious bronchiolitis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">PTTM should be suspected in oncological patients with worsening respiratory function and/or who develop acute/subacute <span class="elsevierStyleItalic">cor pulmonale</span>, particularly in the absence of pulmonary artery embolisms on chest CT angiogram. Detection of a “tree-in-bud” pattern without clinical signs of respiratory infection should also alert to this diagnosis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gorospe Sarasúa L, Ureña-Vacas A, García-Santana E. Diagnóstico radiológico de microangiopatía trombótica tumoral pulmonar: una causa no bronquial de patrón de «árbol en brote» en tomografía computarizada. Arch Bronconeumol. 2016;52:621–622.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 610 "Ancho" => 2067 "Tamanyo" => 213985 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Axial image of chest CT (pulmonary parenchymal window) showing linear thickening of the subpleural lung interstitium (arrows). (B) Maximum intensity projection (MIP) axial reconstruction (pulmonary parenchymal window) of left lung, showing a peripheral “tree-in-bud” pattern consisting of linear opacities forming predominantly subpleural branches (circled). See also the presence of small centrilobular nodules (arrow). (C) MIP coronal reconstruction (pulmonary parenchymal window) of the left lung, also showing the “tree-in-bud” pattern (circled). (D) Chest CT sagittal image (bone window) revealing multiple focal bone lesions (arrows) in the sternum and several vertebrae, consistent with bone metastases.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary tumor thrombotic microangiopathy: the challenge of the <span class="elsevierStyleItalic">antemortem</span> diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Patrignani" 1 => "A. Purcaro" 2 => "F. Calcagnoli" 3 => "A. Mandolesi" 4 => "I. Bearzi" 5 => "N. Ciampani" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Cardiovasc Med" "fecha" => "2014" "volumen" => "15" "paginaInicial" => "828" "paginaFinal" => "833" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary tumour thrombotic microangiopathy: unclassifiable pulmonary hypertension" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "N. Kumar" 1 => "L.C. Price" 2 => "M.A. Montero" 3 => "K. Dimopoulos" 4 => "A.U. Wells" 5 => "S.J. Wort" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/13993003.00052-2015" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2015" "volumen" => "46" "paginaInicial" => "1214" "paginaFinal" => "1217" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26206876" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary tumor thrombotic microangiopathy: a clinical analysis of 30 autopsy cases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Uruga" 1 => "T. Fujii" 2 => "A. Kurosaki" 3 => "S. Hanada" 4 => "H. Takaya" 5 => "A. Miyamoto" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Intern Med" "fecha" => "2013" "volumen" => "52" "paginaInicial" => "1317" "paginaFinal" => "1323" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23774540" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful <span class="elsevierStyleItalic">antemortem</span> diagnosis and treatment of pulmonary tumor thrombotic microangiopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "K. Higo" 1 => "K. Kubota" 2 => "A. Takeda" 3 => "M. Higashi" 4 => "M. Ohishi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Intern Med" "fecha" => "2014" "volumen" => "53" "paginaInicial" => "2595" "paginaFinal" => "2599" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25400181" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thrombotic microangiopathy of pulmonary tumors: a vascular cause of tree-in-bud pattern on CT" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T. Franquet" 1 => "A. Giménez" 2 => "R. Prats" 3 => "J.M. Rodríguez-Arias" 4 => "C. Rodríguez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Roentgenol" "fecha" => "2002" "volumen" => "179" "paginaInicial" => "897" "paginaFinal" => "899" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005200000012/v1_201611260059/S1579212916302221/v1_201611260059/en/main.assets" "Apartado" => array:4 [ "identificador" => "49861" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005200000012/v1_201611260059/S1579212916302221/v1_201611260059/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212916302221?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 5 | 10 |
| 2024 October | 99 | 22 | 121 |
| 2024 September | 74 | 29 | 103 |
| 2024 August | 82 | 40 | 122 |
| 2024 July | 55 | 24 | 79 |
| 2024 June | 67 | 24 | 91 |
| 2024 May | 86 | 35 | 121 |
| 2024 April | 53 | 29 | 82 |
| 2024 March | 56 | 20 | 76 |
| 2024 February | 42 | 15 | 57 |
| 2023 March | 19 | 7 | 26 |
| 2023 February | 76 | 21 | 97 |
| 2023 January | 45 | 33 | 78 |
| 2022 December | 69 | 33 | 102 |
| 2022 November | 75 | 30 | 105 |
| 2022 October | 82 | 34 | 116 |
| 2022 September | 33 | 30 | 63 |
| 2022 August | 43 | 39 | 82 |
| 2022 July | 24 | 46 | 70 |
| 2022 June | 33 | 40 | 73 |
| 2022 May | 51 | 48 | 99 |
| 2022 April | 43 | 32 | 75 |
| 2022 March | 38 | 35 | 73 |
| 2022 February | 32 | 31 | 63 |
| 2022 January | 49 | 53 | 102 |
| 2021 December | 41 | 40 | 81 |
| 2021 November | 51 | 44 | 95 |
| 2021 October | 43 | 55 | 98 |
| 2021 September | 35 | 47 | 82 |
| 2021 August | 43 | 59 | 102 |
| 2021 July | 22 | 42 | 64 |
| 2021 June | 33 | 48 | 81 |
| 2021 May | 37 | 34 | 71 |
| 2021 April | 116 | 102 | 218 |
| 2021 March | 90 | 31 | 121 |
| 2021 February | 55 | 29 | 84 |
| 2021 January | 47 | 24 | 71 |
| 2020 December | 53 | 40 | 93 |
| 2020 November | 71 | 25 | 96 |
| 2020 October | 72 | 24 | 96 |
| 2020 September | 57 | 17 | 74 |
| 2020 August | 48 | 20 | 68 |
| 2020 July | 58 | 34 | 92 |
| 2020 June | 50 | 15 | 65 |
| 2020 May | 54 | 14 | 68 |
| 2020 April | 55 | 31 | 86 |
| 2020 March | 39 | 9 | 48 |
| 2020 February | 63 | 24 | 87 |
| 2020 January | 48 | 35 | 83 |
| 2019 December | 70 | 28 | 98 |
| 2019 November | 52 | 33 | 85 |
| 2019 October | 27 | 14 | 41 |
| 2019 September | 53 | 27 | 80 |
| 2019 August | 54 | 23 | 77 |
| 2019 July | 48 | 15 | 63 |
| 2019 June | 38 | 19 | 57 |
| 2019 May | 46 | 32 | 78 |
| 2019 April | 46 | 52 | 98 |
| 2019 March | 51 | 49 | 100 |
| 2019 February | 35 | 37 | 72 |
| 2019 January | 34 | 24 | 58 |
| 2018 December | 33 | 22 | 55 |
| 2018 November | 63 | 26 | 89 |
| 2018 October | 71 | 32 | 103 |
| 2018 September | 46 | 12 | 58 |
| 2018 May | 16 | 1 | 17 |
| 2018 April | 45 | 7 | 52 |
| 2018 March | 37 | 5 | 42 |
| 2018 February | 37 | 15 | 52 |
| 2018 January | 132 | 8 | 140 |
| 2017 December | 123 | 10 | 133 |
| 2017 November | 36 | 10 | 46 |
| 2017 October | 28 | 9 | 37 |
| 2017 September | 21 | 6 | 27 |
| 2017 August | 30 | 24 | 54 |
| 2017 July | 32 | 14 | 46 |
| 2017 June | 29 | 25 | 54 |
| 2017 May | 27 | 18 | 45 |
| 2017 April | 38 | 27 | 65 |
| 2017 March | 20 | 18 | 38 |
Show all
