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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">Combined pulmonary fibrosis and emphysema &#40;CPFE&#41; is a syndrome characterized by the coexistence of emphysema in the upper lobes and pulmonary fibrosis predominantly in the lower lobes&#44; associated with a distinctive functional profile&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;2</span></a> Spirometric values appear to be practically unchanged&#44; contrasting with a severe reduction in alveolar diffusing capacity &#40;DL<span class="elsevierStyleInf">CO</span>&#41;&#44; hypoxemia&#44; and desaturation on exertion&#46; The most notable complications include pulmonary hypertension &#40;PH&#41;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;4</span></a> and lung cancer &#40;LC&#41;&#44; described in up to 47&#37; of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a> both of which are determinant factors in patient survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Information regarding the prevalence&#44; characteristics&#44; and prognosis of LC in CPFE is almost entirely derived from series in Asian populations&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">5&#44;7&#8211;17</span></a> Recently&#44; Girard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> published the first description of the characteristics of LC in CPFE in a retrospective European cohort study conducted in France&#46; In this study&#44; poor prognosis was mainly attributed to limited therapeutic options in the management of these patients&#44; due to their poor functional residual capacity and greater risk of complications after surgery or oncological treatment&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">No studies have been performed in our setting to explore the relationship between LC and CPFE&#44; so our aim was to analyze the influence of LC on survival in a series of CPFE patients&#46; Clinical&#44; functional and radiological data were compared with a series of patients with idiopathic pulmonary fibrosis &#40;IPF&#41;&#44; since this disease is also known to involve a greater risk of developing LC compared to the general population&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">19&#8211;21</span></a> Secondary objectives included a description of the prevalence and characteristics of LC in both groups&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This was an observational&#44; retrospective&#44; cohort study of 2 patient groups &#40;patients with a diagnosis of CPFE and patients with a diagnosis of IPF&#41; recruited between December 2009 and December 2014&#46; Patients were seen in the dedicated interstitial pulmonary disease &#40;ILD&#41; clinic of a third-level university hospital&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients with a diagnosis of CPFE were included using the criteria of Cottin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> and Brillet et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">2</span></a>&#58; &#40;a&#41; evidence of areas of well-defined emphysema on high-resolution computed tomography &#40;HRCT&#41;&#44; defined as reduced attenuation compared with normal contiguous pulmonary parenchyma&#44; delimited by a very thin wall &#40;&#60;1<span class="elsevierStyleHsp" style=""></span>mm&#41; or no wall&#44; and&#47;or multiple bullae &#40;&#62;1<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; predominantly in the upper lobes&#59; the emphysematous lesions&#44; described as a percentage of affected lung&#44; had to be more than 10&#37;&#59; and &#40;b&#41; presence of DILD with significant characteristics of pulmonary fibrosis&#44; defined as reticular pulmonary opacities predominantly in the periphery and bases&#44; honeycombing&#44; distorted lung architecture and&#47;or retraction&#44; bronchiectasis&#44; or bronchiolectasis&#46; Opacities and&#47;or focal areas of ground glass alveolar consolidation may be associated with this pattern&#44; but must not be prominent&#46; The diagnosis of IPF was made on the basis of the SEPAR diagnostic and therapeutic guidelines for IPF&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">22</span></a> which establish that the definitive diagnosis of IPF requires&#58; &#40;a&#41; exclusion of other defined clinical entities or diffuse pulmonary parenchymal diseases of known etiology &#40;environmental or occupational exposure&#44; connective tissue diseases&#44; drug toxicity&#41;&#44; and &#40;b&#41; presence of a histological pattern of usual interstitial pneumonia &#40;UIP&#41; in the study of lung tissue obtained by surgical lung biopsy&#44; or else radiological evidence of the UIP pattern on HRCT&#44; or both&#46; Cases with inconclusive diagnoses were reviewed by the ILD multidisciplinary committee of our hospital &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Echocardiography data were collected from patients with a clinical or radiological suspicion of PH&#46; The arbitrary criteria proposed by Gali&#232; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a> were used to evaluate the presence of PH&#46; In patients with a diagnosis of LC&#44; initial symptoms&#44; fiberoptic bronchoscopy &#40;FB&#41; findings&#44; staging&#44; histology&#44; treatment and months of survival after diagnosis were collected&#46; All patients were initially staged according to the seventh edition of the TNM classification&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">24</span></a> with pathological staging according to the World Health Organization classification&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Acute exacerbation of pulmonary fibrosis was defined as respiratory deterioration with no identifiable cause&#44; according to the criteria proposed by Collard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">26</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">For analysis of mortality&#44; the following data were recorded&#58; &#40;a&#41; date of diagnosis of CPFE and IPF&#44; &#40;b&#41; date of diagnosis of LC&#44; and &#40;c&#41; date of death&#46; The latter was confirmed from digital clinical records and&#47;or the hospital death records&#46; Lung function tests and the 6-minute walk test &#40;6MWT&#41; were performed according to international recommendations&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">27&#8211;30</span></a> The composite physiologic index &#40;CPI&#41; was calculated using the following formula&#58; 91&#8722;&#40;0&#46;65&#215;percentage predicted DL<span class="elsevierStyleInf">CO</span>&#41;&#8211;&#40;0&#46;53&#215;percentage predicted forced vital capacity &#91;FVC&#93;&#41;&#43;&#40;0&#46;34&#215;percentage predicted forced expiratory volume in 1 second &#91;FEV<span class="elsevierStyleInf">1</span>&#93;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical Analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Data were analyzed using the Stata statistical package&#44; version 13 &#40;StataCorp LP&#44; College Station&#44; USA&#41;&#46; All data were tabulated as mean and standard deviation for quantitative variables and as absolute numbers and percentages for qualitative variables&#46; Survival curves for the groups were constructed according to the Kaplan&#8211;Meier methods and compared using the log-rank test&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 66 patients were included&#44; 29 in the CPFE group and 37 in the IPF group&#46; Median follow-up was 24&#46;3 months &#40;interquartile range 11&#46;4&#8211;42&#46;5&#41;&#46; All CPFE patients were men and had a significantly higher accumulated pack-year index than patients with IPF &#40;<span class="elsevierStyleItalic">p</span>&#60;&#46;001&#41;&#46; Patients with CPFE had significantly higher values in the following functional parameters &#40;expressed as percentage of predicted value&#41;&#58; FVC&#44; ratio of forced expiratory volume in 1 second &#40;FEV<span class="elsevierStyleInf">1</span>&#41; and FVC &#40;FEV<span class="elsevierStyleInf">1</span>&#47;FVC&#41;&#44; total lung capacity &#40;TLC&#41;&#44; and residual volume&#46; DL<span class="elsevierStyleInf">CO</span> and DL<span class="elsevierStyleInf">CO</span>&#47;alveolar volume ratio were also lower compared to patients with IPF &#40;<span class="elsevierStyleItalic">p</span>&#60;&#46;05&#41;&#46; PH estimated by echocardiography was more common in patients with CPFE &#40;45&#37; vs 22&#37; in the IPF group&#41;&#46; These patients had higher systolic blood pressure&#44; and a greater tricuspid regurgitation velocity compared to patients with IPF &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;047 and &#46;023&#44; respectively&#41;&#46; These data are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">CPFE and IPF diagnosis preceded LC diagnosis by a mean of 9&#46;8 months in all patients&#46; Nine patients had a diagnosis of LC &#40;13&#46;6&#37;&#41;&#59; 6 of them &#40;66&#46;6&#37;&#41; had CPFE&#46; All patients in this group were men with a history of smoking&#46; The prevalence of LC in this series was 20&#37; among patients with CPFE and 8&#37; among those with IPF&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The initial suspicion of LC in all patients was radiological&#44; detected in routine follow-up HRCTs &#40;67&#37;&#41;&#46; Three patients reported an increase in habitual cough and had a diagnosis of acute bronchial infection &#40;33&#37;&#41;&#46; The tumor was visible on the chest radiograph of 5 of the 9 patients &#40;55&#37;&#41;&#46; In 2 cases &#40;22&#37;&#41;&#44; the tumor lesion was situated adjacent to areas of pulmonary fibrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Most tumors were located in upper lobes&#44; and 5 were within the areas of emphysema &#40;56&#37;&#41;&#46; The most widely used diagnostic strategy was FB&#44; followed by real-time endobronchial ultrasound with transbronchial needle aspiration &#40;EBUS-TBNA&#41; and computed tomography-guided core needle biopsy &#40;CT-CNB&#41;&#46; A pathology diagnosis was not obtained from 3 patients &#40;33&#37;&#41;&#46; The most common histological subtype was adenocarcinoma&#58; 6 patients had localized stages &#40;<span class="elsevierStyleSmallCaps">I</span>&#8211;II&#41; at the time of diagnosis &#40;67&#37;&#41;&#46; Only 2 patients received surgical treatment&#44; one of whom died on day 17 post-surgery &#40;bilobectomy&#41;&#46; The other underwent lobectomy&#44; followed by adjuvant chemotherapy&#44; and has survived 39 months to date&#46; The most common treatment modality was palliative care&#46; Most commonly observed complications were exacerbations of pulmonary fibrosis in 4 patients &#40;44&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The survival curve did not reveal any differences between CPFE patients compared to IPF patients &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;10&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Twelve-month survival in patients with LC was 0&#46;78 &#40;95&#37; confidence interval &#91;CI&#93;&#58; 0&#46;36&#8211;0&#46;94&#41;&#46; Survival at 24 months was 0&#46;67 &#40;95&#37; CI&#58; 0&#46;28&#8211;0&#46;88&#41;&#46; Survival at 36 months was 0&#46;13 &#40;95&#37; CI&#58; 0&#46;01&#8211;0&#46;44&#41;&#46; In patients without LC&#44; accumulated survival at 12&#44; 24&#44; 36&#44; and 48 months was 0&#46;85 &#40;95&#37; CI&#58; 0&#46;73&#8211;0&#46;92&#41;&#44; 0&#46;74 &#40;95&#37; CI&#58; 0&#46;59&#8211;0&#46;84&#41;&#44; 0&#46;59 &#40;95&#37; CI&#58; 0&#46;43&#8211;0&#46;73&#41;&#44; and 0&#46;49 &#40;95&#37; CI&#58; 0&#46;32&#8211;0&#46;64&#41;&#44; respectively&#46; The difference in survival between the 2 groups was statistically significant &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;044&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; In the multivariate analysis&#44; the odds ratio &#40;OR&#41; of death among patients with LC compared to patients without LC was 6&#46;20 &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;037&#44; 95&#37; CI&#58; 1&#46;11&#8211;34&#46;48&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Our data show that LC significantly reduces survival in patients with CPFE and IPF&#46; The risk of death with this complication is up to 6 times greater compared to patients without LC&#46; Lack of success in diagnosing the histological type in a third of cases and the high rate of complications after the selected treatment modality underline the difficulties in the diagnosis and management of LC in this group of patients&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">To our knowledge&#44; this is the first study to describe a series of CPFE patients in Spain&#46; Data on the prognosis of LC in CPFE are mostly derived from Asian series&#44; and these results need to be replicated in other ethnic groups&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a> In contrast&#44; the influence of LC on IPF has been widely studied in different populations&#44; and identified as an independent factor of death in this entity&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">19&#8211;21&#44;32&#8211;34</span></a> Girard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> performed a study in 47 patients with CPFE&#58; in 9 &#40;19&#37;&#41; of these patients a diagnosis of LC could not be obtained&#46; Twenty patients &#40;42&#37;&#41; could not be given the cancer treatment recommended in the international guidelines due to their functional characteristics&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In our series&#44; CPFE patients met the characteristics described above&#44; and their functional profile was specific and different from that of patients with IPF&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;5&#44;6</span></a> They were mainly men&#44; with a history of smoking and a higher pack-year index that the IPF group&#46; The cohorts studied in the literature are mostly men&#44; but the significance of this finding remains unclear&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6&#44;35</span></a> They had higher than predicted percentages of FVC and TLC&#44; and&#44; in contrast&#44; profound changes in DL<span class="elsevierStyleInf">CO</span>&#46; In CPFE&#44; PH is a cardiovascular complication associated with poorer prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;4</span></a> In line with previous studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a> PH estimated by echocardiography in our patients was more common in the CPFE group&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">It is sometimes difficult to distinguish between these 2 entities in daily clinical practice&#44; and it is essential for cases to be discussed by a ILD multidisciplinary team before reaching a differential diagnosis&#46; The CPI has been shown to have a better predictive value than individual functional parameters in the follow-up of IPF patients<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6&#44;31</span></a>&#59; however&#44; in our study&#44; we did not find this measurement useful for differentiation&#46; It would be useful to have studies analyzing new functional or radiological indices that might reflect the degree of functional and involvement that characterize CPFE patients&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In our study&#44; the prevalence of LC was higher in the CPFE group &#40;20&#37; vs 8&#37; in IPF patients&#41;&#59; however&#44; due to the small sample size&#44; this result must be interpreted with caution&#46; Kwak et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> found a significantly higher risk of LC among CPFE patients than in patients with isolated emphysema&#44; but they did not find significant differences in patients with IPF&#46; Reports in the literature show that 1 in 10 patients with IPF develop LC&#44; with a variable prevalence&#44; reaching up to 48&#37; in autopsy studies&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a> Some authors consider that the greatest risk of LC in CPFE patients is due to the combined &#8220;triple effect&#8221; in these patients of smoking&#44; emphysema&#44; and pulmonary fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a> Cigarette smoke is the main causative agent of LC &#40;90&#37; of cases&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> while emphysema has been shown to be an independent risk factor for the development of this entity&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">36&#44;37</span></a> In line with this observation&#44; though at odds with other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">12&#44;32</span></a> we found that lesions were located in areas of emphysema in almost 2 thirds of LC cases&#46; In this respect&#44; the information on the tumor site is limited in published series&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> Most tumors were located in the upper lobes&#44; consistent with the western cohort described by Girard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Although both entities represent a risk group for the development of LC&#44; current clinical guidelines contain no recommendations on screening strategies in these diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">22&#44;36</span></a> The lack of diagnosis in one third of our cases shows the difficulty of using invasive procedures in patients with a high risk of complications&#44; given their parenchymal changes&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In non-small cell LC stages <span class="elsevierStyleSmallCaps">I</span> and <span class="elsevierStyleSmallCaps">II</span>&#44; radical surgery offers the best possibility of cure&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> However&#44; several recent studies have indicated a poorer prognosis in both CPFE and IPF patients after surgical resection&#44; due to a higher rate of post-operative complications &#40;particularly acute exacerbation of pulmonary fibrosis and early LC relapse&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;21&#44;32&#44;34</span></a> In our series&#44; only 2 patients were receiving surgical treatment&#44; so it is difficult to extract conclusions in this respect&#46; However&#44; the patient who has survived&#44; disease-free&#44; until the time of writing underwent lobectomy&#44; in contrast to the other patient who died in the late post-operative period &#40;after bilobectomy&#41;&#46; This observation is in line with previous studies that supported more conservative surgical interventions in these patients&#44; such as segmentectomy or lobectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">21&#44;34&#44;38</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Although 67&#37; of LC patients were in stages <span class="elsevierStyleSmallCaps">I</span>&#8211;<span class="elsevierStyleSmallCaps">II</span>&#44; the most widely used treatment modality was palliative care&#46; Treatment with chemotherapy or radiation therapy &#40;2 cases with both treatments&#41; was also an ineffective option&#46; The most common complication in LC patients was exacerbation of pulmonary fibrosis&#44; an event commonly described in the published series&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">13&#44;34&#44;38</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In this study&#44; LC significantly reduced patient survival and was associated with a 6-fold increase in mortality rate compared to patients without LC&#46; In accordance with our findings&#44; Tomassetti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> reported a hazard ratio of 7 in a cohort of 186 patients with IPF&#46; In another recent study&#44; LC was a significant predictor of death in the &#8220;comorbidome&#8221; of patients with IPF&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">CPFE per se has been identified by some authors as an independent prognostic factor for LC relapse and survival&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">14</span></a> Girard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> confirmed the unfavorable prognosis of LC in these patients&#44; in line with our results and with those of the Asian cohort studies&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">As for overall mortality&#44; we found no significant differences between patients with CPFE and IPF&#44; a finding that coincides with those of Jankowich and Rounds<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">39</span></a> in a study with a very similar sample and follow-up to ours&#46; In this respect&#44; most studies available to date confirm that the already precarious survival in both entities is substantially affected by extrapulmonary comorbidities &#40;cardiovascular disease&#44; including PH&#44; gastroesophageal reflux&#44; and LC<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;4&#44;6&#44;9&#8211;21&#44;32&#8211;34</span></a>&#41;&#46; Newly approved drugs for the treatment of IPF &#40;pirfenidone and nintedanib&#41; offer new possibilities in this respect&#44; and may help modify the natural disease course of this entity&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> Future studies will be needed to compare historical cohorts and analyze the impact of these treatments on survival and incidence of comorbidities&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">We recognize that our study has some limitations that prevent generalization of our results&#46; Firstly&#44; it was carried out in a single center and its retrospective design may introduce limitations in data analysis&#46; Since the primary objective of this study was to analyze the impact of LC on mortality of CPFE and IPF patients for the first time in a Spanish series&#44; our findings answer the research question&#46; Secondly&#44; we cannot establish the influence of new&#44; recently approved antifibrotic treatments on the incidence of LC or on the overall survival of the series&#46; We believe that this fact does not affect the results presented here&#44; given the low number of treated patients included in the sample at the time of recruitment&#46; Finally&#44; 2 relatively small patient groups were studied&#44; with the consequent limitation on comparisons and the extrapolation of results&#46; However&#44; we believe that our sample is representative of patients treated in real-world situations in third-level hospitals in our setting&#46; Investigational collaboration and national multicenter registries are needed to generate more information on this topic&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results show that in patients with CPFE and IPF&#44; LC is a complication that demonstratively increases mortality&#46; These patients are more vulnerable to developing complications related with the selected anticancer treatment&#44; even after palliative management&#46; These considerations must be taken into account in clinical guidelines&#44; in order to help standardize the diagnostic and therapeutic approach to LC in these patients&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">Karina Portillo Carroz received a research grant from the Spanish Society of Pulmonology and Thoracic Surgery &#40;2013&#41; and an &#8220;EPID-futuro&#8221; grant sponsored by Roche &#40;2013&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of Interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-06-13"
    "fechaAceptado" => "2016-10-08"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec856897"
          "palabras" => array:3 [
            0 => "Combined pulmonary fibrosis and emphysema"
            1 => "Idiopathic pulmonary fibrosis"
            2 => "Lung cancer"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec856896"
          "palabras" => array:3 [
            0 => "Combinaci&#243;n de fibrosis pulmonar y enfisema"
            1 => "Fibrosis pulmonar idiop&#225;tica"
            2 => "C&#225;ncer de pulm&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Information on the association of lung cancer &#40;LC&#41; and combined pulmonary fibrosis and emphysema &#40;CPFE&#41; is limited and derived almost exclusively from series in Asian populations&#46; The main objective of the study was to assess the impact of LC on survival in CPFE patients and in patients with idiopathic pulmonary fibrosis &#40;IPF&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was performed with data from patients with CPFE and IPF diagnosed in our hospital over a period of 5 years&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sixty-six patients were included&#44; 29 with CPFE and 37 with IPF&#46; Nine had a diagnosis of LC &#40;6 with CPFE and 3 with IPF&#41;&#46; Six patients &#40;67&#37;&#41; received palliative treatment even though 3 of them were diagnosed atstage I&#8211;II&#46; Overall mortality did not differ significantly between groups&#59; however&#44; in patients with LC&#44; survival was significantly lower compared to those without LC &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;044&#41;&#46; The most frequent cause of death was respiratory failure secondary to pulmonary fibrosis exacerbation &#40;44&#37;&#41;&#46; In a multivariate analysis&#44; the odds ratio of death among patients with LC compared to patients without LC was 6&#46;20 &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;037&#44; 95&#37; confidence interval&#58; 1&#46;11&#8211;34&#46;48&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lung cancer reduces survival in both entities&#46; The diagnostic and therapeutic management of LC is hampered by the increased risk of complications after any treatment modality&#44; even after palliative treatment&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La informaci&#243;n sobre la asociaci&#243;n del c&#225;ncer de pulm&#243;n &#40;CP&#41; y combinaci&#243;n de fibrosis pulmonar y enfisema &#40;CFPE&#41; es limitada y procedente casi exclusivamente de series asi&#225;ticas&#46; El objetivo principal del estudio fue valorar el impacto del CP en la supervivencia en la CFPE y en pacientes diagnosticados de fibrosis pulmonar idiop&#225;tica &#40;FPI&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio retrospectivo con los datos de pacientes con CFPE y FPI diagnosticados en nuestro centro en un periodo de 5 a&#241;os&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a 66 pacientes&#44; 29 en el grupo de CFPE y 37 pacientes con FPI&#46; Nueve ten&#237;an un diagn&#243;stico de CP &#40;6 con CFPE y 3 con FPI&#41;&#59; 6 pacientes &#40;67&#37;&#41; recibieron tratamiento paliativo a pesar de que 3 de ellos presentaban estadios <span class="elsevierStyleSmallCaps">i</span> y <span class="elsevierStyleSmallCaps">ii</span>&#46; No hubo diferencias significativas en la mortalidad global de los 2 grupos&#59; sin embargo&#44; en los pacientes con CP la supervivencia fue significativamente menor con respecto a los que no ten&#237;an CP &#40;p&#61;&#44;044&#41;&#46; Las causas m&#225;s frecuentes de muerte fue la insuficiencia respiratoria secundaria a la exacerbaci&#243;n de la fibrosis pulmonar &#40;44&#37;&#41;&#46; En el an&#225;lisis multivariante&#44; la <span class="elsevierStyleItalic">odds ratio</span> de morir en los pacientes con CP respecto a los pacientes sin CP fue de 6&#44;20 &#40;p&#61;&#44;037&#44; intervalo de confianza &#91;IC&#93; del 95&#37;&#58; 1&#44;11 a 34&#44;48&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El CP empeora la supervivencia de estas 2 entidades&#46; El manejo diagn&#243;stico y terap&#233;utico del CP se ve dificultado por el mayor riesgo de complicaciones posteriores al tratamiento elegido&#44; incluso tras el tratamiento paliativo&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Portillo K&#44; Perez-Rodas N&#44; Garc&#237;a-Oliv&#233; I&#44; Guasch-Arriaga I&#44; Centeno C&#44; Serra P&#44; et al&#46; C&#225;ncer de pulm&#243;n en pacientes con combinaci&#243;n de fibrosis pulmonar y enfisema y fibrosis pulmonar idiop&#225;tica&#46; Estudio descriptivo en una serie espa&#241;ola&#46; Arch Bronconeumol&#46; 2017&#59;53&#58;304&#8211;310&#46;</p>"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1397
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient screening flow chart&#46; CPFE&#58; combined pulmonary fibrosis and emphysema&#59; LC&#58; lung cancer&#59; DILD&#58; diffuse interstitial pulmonary disease&#59; IPF&#58; idiopathic pulmonary fibrosis&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patient with CPFE and LC&#46; &#40;A&#41; Chest radiograph &#40;posteroanterior projection&#41;&#58; Poorly defined nodular focal pulmonary opacity &#40;arrow&#41; is observed in the base of the left lung&#44; and a reticular interstitial involvement in both lung bases&#46; &#40;B&#41; HRCT showing presence of emphysema in the upper lobes&#46; &#40;C&#41; Chest HRCT confirming presence of a pulmonary mass with lobulated and spiculated borders &#40;arrow head&#41; in the lingula&#44; adjacent to an area of honeycombing&#46; CPFE&#58; combined pulmonary fibrosis and emphysema&#59; LC&#58; lung cancer&#59; HRCT&#58; high-resolution computed tomography&#46;</p>"
        ]
      ]
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        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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            "imagen" => "gr3.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Comparison of survival by presence of IPF or CPFE&#46; CPFE&#58; combined pulmonary fibrosis and emphysema&#59; IPF&#58; idiopathic pulmonary fibrosis&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Comparison of survival by presence or absence of LC&#46; LC&#58; lung cancer&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">6MWT&#58; 6-minute walk test&#59; &#37; pred&#58; percentage of predicted value&#59; AV&#58; alveolar volume&#59; CPFE&#58; combined pulmonary fibrosis and emphysema&#59; CPI&#58; composite physiologic index&#59; DL<span class="elsevierStyleInf">CO</span>&#58; diffusing capacity of the lung for carbon monoxide&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in 1 second&#59; FEV<span class="elsevierStyleInf">1</span>&#47;FVC&#58; forced expiratory volume in 1 second and forced vital capacity ratio expressed as an absolute percentage&#59; FVC&#58; forced vital capacity&#59; IPF&#58; idiopathic pulmonary fibrosis&#59; PH&#58; pulmonary hypertension&#59; RV&#58; residual volume&#59; RV&#47;TLC&#58; ratio of RV and total lung capacity&#59; SPB&#58; systolic blood pressure&#59; SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleInf">final</span>&#58; oxygen saturation at end of 6MWT&#59; SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleInf">initial</span>&#58; oxygen saturation at start of 6MWT&#59; TLC&#58; total lung capacity&#59; TR&#58; tricuspid regurgitation&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Data are presented as mean&#177;SD&#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"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CPFE &#40;<span class="elsevierStyleItalic">n</span>&#61;29&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&#177;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&#177;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&#47;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#47;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Active smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Former smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Never smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pack-years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#177;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#177;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#177;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FEV<span class="elsevierStyleInf">1</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&#177;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&#177;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FEV<span class="elsevierStyleInf">1</span>&#47;FVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&#177;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&#177;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TLC &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&#177;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#177;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RV &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">117&#177;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&#177;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RV&#47;TLC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">118&#177;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">94&#177;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;052&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DL<span class="elsevierStyleInf">CO</span> &#40;&#37; pred&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&#177;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#177;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DLCO&#47;AV &#40;&#37; pred&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&#177;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&#177;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CPI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&#177;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&#177;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6MWT &#40;m&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">369&#177;150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">421&#177;113&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleInf">initial</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95&#177;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96&#177;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleInf">final</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&#177;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&#177;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PH<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SBP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#177;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#177;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;047&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TR speed &#40;m<span class="elsevierStyleHsp" style=""></span>s<span class="elsevierStyleSup">&#8722;1</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;1&#177;0&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;4&#177;0&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">ABI&#58; acute bronchial infection&#59; CVA&#58; cerebrovascular accident&#59; CPFE&#58; combined pulmonary fibrosis and emphysema&#59; chemoherapy&#58; chemotherapy&#59; CT-CNB&#58; computed tomography-guided core needle biopsy&#59; EBUS-TBNA&#58; real-time endobronchial ultrasound-transbronchial needle aspiration&#59; FB&#58; fiberoptic bronchoscopy&#59; IPF&#58; idiopathic pulmonary fibrosis&#59; LLL&#58; left lower lobe&#59; LUL&#58; left upper lobe&#59; M&#47;F&#58; male&#47;female&#59; MT&#58; metastasis&#59; NA&#58; not applicable&#59; PET-CT&#58; positron emission tomography-computed tomography&#59; PTE&#58; pulmonary thromboembolism&#59; RLL&#58; right lower lobe&#59; RUL&#58; right lower lobe&#59; RT&#58; radiation therapy&#59; SR&#58; surgical resection&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N&#46;&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex &#40;M&#47;F&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Smoking Habit &#40;Yes&#47;No&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial Manifestation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic Technique&#47;Staging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pathology Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Site of Cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Stage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cause of Death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FB&#47;EBUS-TBNA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LLL &#40;adjacent to honeycombing&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exacerbation of pulmonary fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hemorrhagic CVA due to brain MT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ABI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FB&#47;EBUS-TBNA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Squamous carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RLL &#40;unaffected zone&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IIB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bronchoarterial fistula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hemoptysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mediastinoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RUL &#40;adjacent to emphysema&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SR&#43;chemoherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumothorax&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT-CNB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inconclusive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LUL &#40;lingula&#41; &#40;adjacent to honeycombing&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RT&#47;palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exacerbation of pulmonary fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Respiratory failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ABI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT-CNB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LUL &#40;adjacent to emphysema&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">chemoherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exacerbation of pulmonary fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Respiratory failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FB&#47;EBUS-TBNA<br>PET-CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inconclusive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left hilar lesion infiltrating pulmonary artery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IIIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PTE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sepsis of respiratory origin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IPF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inconclusive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RUL &#40;unaffected zone&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exacerbation of pulmonary fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Respiratory failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IPF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT-CNB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LUL &#40;adjacent to emphysema&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PTE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Respiratory failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IPF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ABI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Atypical cells suggestive of malignancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RUL &#40;adjacent to emphysema&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiorgan failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Characteristics&#44; Treatment and Progress of Patients with Lung Cancer&#46;</p>"
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Original Article
Lung Cancer in Patients With Combined Pulmonary Fibrosis and Emphysema and Idiopathic Pulmonary Fibrosis. A Descriptive Study in a Spanish Series
Cáncer de pulmón en pacientes con combinación de fibrosis pulmonar y enfisema y fibrosis pulmonar idiopática. Estudio descriptivo en una serie española
Karina Portilloa,b,
Corresponding author
karisoe@yahoo.es

Corresponding author.
, Nancy Perez-Rodasa, Ignasi García-Olivéa,c, Ignasi Guasch-Arriagaa, Carmen Centenoa, Pere Serraa, Caroline Becker-Lejueza, José Sanz-Santosa, Felipe Andreoa,b,c,d, Juan Ruiz-Manzanoa,b,c,d
a Servei de Pneumologia, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
b Barcelona Research Network (BRN), Barcelona, Spain
c Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
d Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient screening flow chart&#46; CPFE&#58; combined pulmonary fibrosis and emphysema&#59; LC&#58; lung cancer&#59; DILD&#58; diffuse interstitial pulmonary disease&#59; IPF&#58; idiopathic pulmonary fibrosis&#46;</p>"
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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">Combined pulmonary fibrosis and emphysema &#40;CPFE&#41; is a syndrome characterized by the coexistence of emphysema in the upper lobes and pulmonary fibrosis predominantly in the lower lobes&#44; associated with a distinctive functional profile&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;2</span></a> Spirometric values appear to be practically unchanged&#44; contrasting with a severe reduction in alveolar diffusing capacity &#40;DL<span class="elsevierStyleInf">CO</span>&#41;&#44; hypoxemia&#44; and desaturation on exertion&#46; The most notable complications include pulmonary hypertension &#40;PH&#41;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;4</span></a> and lung cancer &#40;LC&#41;&#44; described in up to 47&#37; of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a> both of which are determinant factors in patient survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Information regarding the prevalence&#44; characteristics&#44; and prognosis of LC in CPFE is almost entirely derived from series in Asian populations&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">5&#44;7&#8211;17</span></a> Recently&#44; Girard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> published the first description of the characteristics of LC in CPFE in a retrospective European cohort study conducted in France&#46; In this study&#44; poor prognosis was mainly attributed to limited therapeutic options in the management of these patients&#44; due to their poor functional residual capacity and greater risk of complications after surgery or oncological treatment&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">No studies have been performed in our setting to explore the relationship between LC and CPFE&#44; so our aim was to analyze the influence of LC on survival in a series of CPFE patients&#46; Clinical&#44; functional and radiological data were compared with a series of patients with idiopathic pulmonary fibrosis &#40;IPF&#41;&#44; since this disease is also known to involve a greater risk of developing LC compared to the general population&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">19&#8211;21</span></a> Secondary objectives included a description of the prevalence and characteristics of LC in both groups&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This was an observational&#44; retrospective&#44; cohort study of 2 patient groups &#40;patients with a diagnosis of CPFE and patients with a diagnosis of IPF&#41; recruited between December 2009 and December 2014&#46; Patients were seen in the dedicated interstitial pulmonary disease &#40;ILD&#41; clinic of a third-level university hospital&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients with a diagnosis of CPFE were included using the criteria of Cottin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> and Brillet et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">2</span></a>&#58; &#40;a&#41; evidence of areas of well-defined emphysema on high-resolution computed tomography &#40;HRCT&#41;&#44; defined as reduced attenuation compared with normal contiguous pulmonary parenchyma&#44; delimited by a very thin wall &#40;&#60;1<span class="elsevierStyleHsp" style=""></span>mm&#41; or no wall&#44; and&#47;or multiple bullae &#40;&#62;1<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; predominantly in the upper lobes&#59; the emphysematous lesions&#44; described as a percentage of affected lung&#44; had to be more than 10&#37;&#59; and &#40;b&#41; presence of DILD with significant characteristics of pulmonary fibrosis&#44; defined as reticular pulmonary opacities predominantly in the periphery and bases&#44; honeycombing&#44; distorted lung architecture and&#47;or retraction&#44; bronchiectasis&#44; or bronchiolectasis&#46; Opacities and&#47;or focal areas of ground glass alveolar consolidation may be associated with this pattern&#44; but must not be prominent&#46; The diagnosis of IPF was made on the basis of the SEPAR diagnostic and therapeutic guidelines for IPF&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">22</span></a> which establish that the definitive diagnosis of IPF requires&#58; &#40;a&#41; exclusion of other defined clinical entities or diffuse pulmonary parenchymal diseases of known etiology &#40;environmental or occupational exposure&#44; connective tissue diseases&#44; drug toxicity&#41;&#44; and &#40;b&#41; presence of a histological pattern of usual interstitial pneumonia &#40;UIP&#41; in the study of lung tissue obtained by surgical lung biopsy&#44; or else radiological evidence of the UIP pattern on HRCT&#44; or both&#46; Cases with inconclusive diagnoses were reviewed by the ILD multidisciplinary committee of our hospital &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Echocardiography data were collected from patients with a clinical or radiological suspicion of PH&#46; The arbitrary criteria proposed by Gali&#232; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a> were used to evaluate the presence of PH&#46; In patients with a diagnosis of LC&#44; initial symptoms&#44; fiberoptic bronchoscopy &#40;FB&#41; findings&#44; staging&#44; histology&#44; treatment and months of survival after diagnosis were collected&#46; All patients were initially staged according to the seventh edition of the TNM classification&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">24</span></a> with pathological staging according to the World Health Organization classification&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Acute exacerbation of pulmonary fibrosis was defined as respiratory deterioration with no identifiable cause&#44; according to the criteria proposed by Collard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">26</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">For analysis of mortality&#44; the following data were recorded&#58; &#40;a&#41; date of diagnosis of CPFE and IPF&#44; &#40;b&#41; date of diagnosis of LC&#44; and &#40;c&#41; date of death&#46; The latter was confirmed from digital clinical records and&#47;or the hospital death records&#46; Lung function tests and the 6-minute walk test &#40;6MWT&#41; were performed according to international recommendations&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">27&#8211;30</span></a> The composite physiologic index &#40;CPI&#41; was calculated using the following formula&#58; 91&#8722;&#40;0&#46;65&#215;percentage predicted DL<span class="elsevierStyleInf">CO</span>&#41;&#8211;&#40;0&#46;53&#215;percentage predicted forced vital capacity &#91;FVC&#93;&#41;&#43;&#40;0&#46;34&#215;percentage predicted forced expiratory volume in 1 second &#91;FEV<span class="elsevierStyleInf">1</span>&#93;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical Analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Data were analyzed using the Stata statistical package&#44; version 13 &#40;StataCorp LP&#44; College Station&#44; USA&#41;&#46; All data were tabulated as mean and standard deviation for quantitative variables and as absolute numbers and percentages for qualitative variables&#46; Survival curves for the groups were constructed according to the Kaplan&#8211;Meier methods and compared using the log-rank test&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 66 patients were included&#44; 29 in the CPFE group and 37 in the IPF group&#46; Median follow-up was 24&#46;3 months &#40;interquartile range 11&#46;4&#8211;42&#46;5&#41;&#46; All CPFE patients were men and had a significantly higher accumulated pack-year index than patients with IPF &#40;<span class="elsevierStyleItalic">p</span>&#60;&#46;001&#41;&#46; Patients with CPFE had significantly higher values in the following functional parameters &#40;expressed as percentage of predicted value&#41;&#58; FVC&#44; ratio of forced expiratory volume in 1 second &#40;FEV<span class="elsevierStyleInf">1</span>&#41; and FVC &#40;FEV<span class="elsevierStyleInf">1</span>&#47;FVC&#41;&#44; total lung capacity &#40;TLC&#41;&#44; and residual volume&#46; DL<span class="elsevierStyleInf">CO</span> and DL<span class="elsevierStyleInf">CO</span>&#47;alveolar volume ratio were also lower compared to patients with IPF &#40;<span class="elsevierStyleItalic">p</span>&#60;&#46;05&#41;&#46; PH estimated by echocardiography was more common in patients with CPFE &#40;45&#37; vs 22&#37; in the IPF group&#41;&#46; These patients had higher systolic blood pressure&#44; and a greater tricuspid regurgitation velocity compared to patients with IPF &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;047 and &#46;023&#44; respectively&#41;&#46; These data are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">CPFE and IPF diagnosis preceded LC diagnosis by a mean of 9&#46;8 months in all patients&#46; Nine patients had a diagnosis of LC &#40;13&#46;6&#37;&#41;&#59; 6 of them &#40;66&#46;6&#37;&#41; had CPFE&#46; All patients in this group were men with a history of smoking&#46; The prevalence of LC in this series was 20&#37; among patients with CPFE and 8&#37; among those with IPF&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The initial suspicion of LC in all patients was radiological&#44; detected in routine follow-up HRCTs &#40;67&#37;&#41;&#46; Three patients reported an increase in habitual cough and had a diagnosis of acute bronchial infection &#40;33&#37;&#41;&#46; The tumor was visible on the chest radiograph of 5 of the 9 patients &#40;55&#37;&#41;&#46; In 2 cases &#40;22&#37;&#41;&#44; the tumor lesion was situated adjacent to areas of pulmonary fibrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Most tumors were located in upper lobes&#44; and 5 were within the areas of emphysema &#40;56&#37;&#41;&#46; The most widely used diagnostic strategy was FB&#44; followed by real-time endobronchial ultrasound with transbronchial needle aspiration &#40;EBUS-TBNA&#41; and computed tomography-guided core needle biopsy &#40;CT-CNB&#41;&#46; A pathology diagnosis was not obtained from 3 patients &#40;33&#37;&#41;&#46; The most common histological subtype was adenocarcinoma&#58; 6 patients had localized stages &#40;<span class="elsevierStyleSmallCaps">I</span>&#8211;II&#41; at the time of diagnosis &#40;67&#37;&#41;&#46; Only 2 patients received surgical treatment&#44; one of whom died on day 17 post-surgery &#40;bilobectomy&#41;&#46; The other underwent lobectomy&#44; followed by adjuvant chemotherapy&#44; and has survived 39 months to date&#46; The most common treatment modality was palliative care&#46; Most commonly observed complications were exacerbations of pulmonary fibrosis in 4 patients &#40;44&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The survival curve did not reveal any differences between CPFE patients compared to IPF patients &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;10&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Twelve-month survival in patients with LC was 0&#46;78 &#40;95&#37; confidence interval &#91;CI&#93;&#58; 0&#46;36&#8211;0&#46;94&#41;&#46; Survival at 24 months was 0&#46;67 &#40;95&#37; CI&#58; 0&#46;28&#8211;0&#46;88&#41;&#46; Survival at 36 months was 0&#46;13 &#40;95&#37; CI&#58; 0&#46;01&#8211;0&#46;44&#41;&#46; In patients without LC&#44; accumulated survival at 12&#44; 24&#44; 36&#44; and 48 months was 0&#46;85 &#40;95&#37; CI&#58; 0&#46;73&#8211;0&#46;92&#41;&#44; 0&#46;74 &#40;95&#37; CI&#58; 0&#46;59&#8211;0&#46;84&#41;&#44; 0&#46;59 &#40;95&#37; CI&#58; 0&#46;43&#8211;0&#46;73&#41;&#44; and 0&#46;49 &#40;95&#37; CI&#58; 0&#46;32&#8211;0&#46;64&#41;&#44; respectively&#46; The difference in survival between the 2 groups was statistically significant &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;044&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; In the multivariate analysis&#44; the odds ratio &#40;OR&#41; of death among patients with LC compared to patients without LC was 6&#46;20 &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;037&#44; 95&#37; CI&#58; 1&#46;11&#8211;34&#46;48&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Our data show that LC significantly reduces survival in patients with CPFE and IPF&#46; The risk of death with this complication is up to 6 times greater compared to patients without LC&#46; Lack of success in diagnosing the histological type in a third of cases and the high rate of complications after the selected treatment modality underline the difficulties in the diagnosis and management of LC in this group of patients&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">To our knowledge&#44; this is the first study to describe a series of CPFE patients in Spain&#46; Data on the prognosis of LC in CPFE are mostly derived from Asian series&#44; and these results need to be replicated in other ethnic groups&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a> In contrast&#44; the influence of LC on IPF has been widely studied in different populations&#44; and identified as an independent factor of death in this entity&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">19&#8211;21&#44;32&#8211;34</span></a> Girard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> performed a study in 47 patients with CPFE&#58; in 9 &#40;19&#37;&#41; of these patients a diagnosis of LC could not be obtained&#46; Twenty patients &#40;42&#37;&#41; could not be given the cancer treatment recommended in the international guidelines due to their functional characteristics&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In our series&#44; CPFE patients met the characteristics described above&#44; and their functional profile was specific and different from that of patients with IPF&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;5&#44;6</span></a> They were mainly men&#44; with a history of smoking and a higher pack-year index that the IPF group&#46; The cohorts studied in the literature are mostly men&#44; but the significance of this finding remains unclear&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6&#44;35</span></a> They had higher than predicted percentages of FVC and TLC&#44; and&#44; in contrast&#44; profound changes in DL<span class="elsevierStyleInf">CO</span>&#46; In CPFE&#44; PH is a cardiovascular complication associated with poorer prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;4</span></a> In line with previous studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a> PH estimated by echocardiography in our patients was more common in the CPFE group&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">It is sometimes difficult to distinguish between these 2 entities in daily clinical practice&#44; and it is essential for cases to be discussed by a ILD multidisciplinary team before reaching a differential diagnosis&#46; The CPI has been shown to have a better predictive value than individual functional parameters in the follow-up of IPF patients<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6&#44;31</span></a>&#59; however&#44; in our study&#44; we did not find this measurement useful for differentiation&#46; It would be useful to have studies analyzing new functional or radiological indices that might reflect the degree of functional and involvement that characterize CPFE patients&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In our study&#44; the prevalence of LC was higher in the CPFE group &#40;20&#37; vs 8&#37; in IPF patients&#41;&#59; however&#44; due to the small sample size&#44; this result must be interpreted with caution&#46; Kwak et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> found a significantly higher risk of LC among CPFE patients than in patients with isolated emphysema&#44; but they did not find significant differences in patients with IPF&#46; Reports in the literature show that 1 in 10 patients with IPF develop LC&#44; with a variable prevalence&#44; reaching up to 48&#37; in autopsy studies&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a> Some authors consider that the greatest risk of LC in CPFE patients is due to the combined &#8220;triple effect&#8221; in these patients of smoking&#44; emphysema&#44; and pulmonary fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a> Cigarette smoke is the main causative agent of LC &#40;90&#37; of cases&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> while emphysema has been shown to be an independent risk factor for the development of this entity&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">36&#44;37</span></a> In line with this observation&#44; though at odds with other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">12&#44;32</span></a> we found that lesions were located in areas of emphysema in almost 2 thirds of LC cases&#46; In this respect&#44; the information on the tumor site is limited in published series&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> Most tumors were located in the upper lobes&#44; consistent with the western cohort described by Girard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Although both entities represent a risk group for the development of LC&#44; current clinical guidelines contain no recommendations on screening strategies in these diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">22&#44;36</span></a> The lack of diagnosis in one third of our cases shows the difficulty of using invasive procedures in patients with a high risk of complications&#44; given their parenchymal changes&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In non-small cell LC stages <span class="elsevierStyleSmallCaps">I</span> and <span class="elsevierStyleSmallCaps">II</span>&#44; radical surgery offers the best possibility of cure&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> However&#44; several recent studies have indicated a poorer prognosis in both CPFE and IPF patients after surgical resection&#44; due to a higher rate of post-operative complications &#40;particularly acute exacerbation of pulmonary fibrosis and early LC relapse&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;21&#44;32&#44;34</span></a> In our series&#44; only 2 patients were receiving surgical treatment&#44; so it is difficult to extract conclusions in this respect&#46; However&#44; the patient who has survived&#44; disease-free&#44; until the time of writing underwent lobectomy&#44; in contrast to the other patient who died in the late post-operative period &#40;after bilobectomy&#41;&#46; This observation is in line with previous studies that supported more conservative surgical interventions in these patients&#44; such as segmentectomy or lobectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">21&#44;34&#44;38</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Although 67&#37; of LC patients were in stages <span class="elsevierStyleSmallCaps">I</span>&#8211;<span class="elsevierStyleSmallCaps">II</span>&#44; the most widely used treatment modality was palliative care&#46; Treatment with chemotherapy or radiation therapy &#40;2 cases with both treatments&#41; was also an ineffective option&#46; The most common complication in LC patients was exacerbation of pulmonary fibrosis&#44; an event commonly described in the published series&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">13&#44;34&#44;38</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In this study&#44; LC significantly reduced patient survival and was associated with a 6-fold increase in mortality rate compared to patients without LC&#46; In accordance with our findings&#44; Tomassetti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> reported a hazard ratio of 7 in a cohort of 186 patients with IPF&#46; In another recent study&#44; LC was a significant predictor of death in the &#8220;comorbidome&#8221; of patients with IPF&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">CPFE per se has been identified by some authors as an independent prognostic factor for LC relapse and survival&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">14</span></a> Girard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> confirmed the unfavorable prognosis of LC in these patients&#44; in line with our results and with those of the Asian cohort studies&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">As for overall mortality&#44; we found no significant differences between patients with CPFE and IPF&#44; a finding that coincides with those of Jankowich and Rounds<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">39</span></a> in a study with a very similar sample and follow-up to ours&#46; In this respect&#44; most studies available to date confirm that the already precarious survival in both entities is substantially affected by extrapulmonary comorbidities &#40;cardiovascular disease&#44; including PH&#44; gastroesophageal reflux&#44; and LC<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;4&#44;6&#44;9&#8211;21&#44;32&#8211;34</span></a>&#41;&#46; Newly approved drugs for the treatment of IPF &#40;pirfenidone and nintedanib&#41; offer new possibilities in this respect&#44; and may help modify the natural disease course of this entity&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> Future studies will be needed to compare historical cohorts and analyze the impact of these treatments on survival and incidence of comorbidities&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">We recognize that our study has some limitations that prevent generalization of our results&#46; Firstly&#44; it was carried out in a single center and its retrospective design may introduce limitations in data analysis&#46; Since the primary objective of this study was to analyze the impact of LC on mortality of CPFE and IPF patients for the first time in a Spanish series&#44; our findings answer the research question&#46; Secondly&#44; we cannot establish the influence of new&#44; recently approved antifibrotic treatments on the incidence of LC or on the overall survival of the series&#46; We believe that this fact does not affect the results presented here&#44; given the low number of treated patients included in the sample at the time of recruitment&#46; Finally&#44; 2 relatively small patient groups were studied&#44; with the consequent limitation on comparisons and the extrapolation of results&#46; However&#44; we believe that our sample is representative of patients treated in real-world situations in third-level hospitals in our setting&#46; Investigational collaboration and national multicenter registries are needed to generate more information on this topic&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results show that in patients with CPFE and IPF&#44; LC is a complication that demonstratively increases mortality&#46; These patients are more vulnerable to developing complications related with the selected anticancer treatment&#44; even after palliative management&#46; These considerations must be taken into account in clinical guidelines&#44; in order to help standardize the diagnostic and therapeutic approach to LC in these patients&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">Karina Portillo Carroz received a research grant from the Spanish Society of Pulmonology and Thoracic Surgery &#40;2013&#41; and an &#8220;EPID-futuro&#8221; grant sponsored by Roche &#40;2013&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of Interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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            1 => "Idiopathic pulmonary fibrosis"
            2 => "Lung cancer"
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            0 => "Combinaci&#243;n de fibrosis pulmonar y enfisema"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Information on the association of lung cancer &#40;LC&#41; and combined pulmonary fibrosis and emphysema &#40;CPFE&#41; is limited and derived almost exclusively from series in Asian populations&#46; The main objective of the study was to assess the impact of LC on survival in CPFE patients and in patients with idiopathic pulmonary fibrosis &#40;IPF&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was performed with data from patients with CPFE and IPF diagnosed in our hospital over a period of 5 years&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sixty-six patients were included&#44; 29 with CPFE and 37 with IPF&#46; Nine had a diagnosis of LC &#40;6 with CPFE and 3 with IPF&#41;&#46; Six patients &#40;67&#37;&#41; received palliative treatment even though 3 of them were diagnosed atstage I&#8211;II&#46; Overall mortality did not differ significantly between groups&#59; however&#44; in patients with LC&#44; survival was significantly lower compared to those without LC &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;044&#41;&#46; The most frequent cause of death was respiratory failure secondary to pulmonary fibrosis exacerbation &#40;44&#37;&#41;&#46; In a multivariate analysis&#44; the odds ratio of death among patients with LC compared to patients without LC was 6&#46;20 &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;037&#44; 95&#37; confidence interval&#58; 1&#46;11&#8211;34&#46;48&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lung cancer reduces survival in both entities&#46; The diagnostic and therapeutic management of LC is hampered by the increased risk of complications after any treatment modality&#44; even after palliative treatment&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La informaci&#243;n sobre la asociaci&#243;n del c&#225;ncer de pulm&#243;n &#40;CP&#41; y combinaci&#243;n de fibrosis pulmonar y enfisema &#40;CFPE&#41; es limitada y procedente casi exclusivamente de series asi&#225;ticas&#46; El objetivo principal del estudio fue valorar el impacto del CP en la supervivencia en la CFPE y en pacientes diagnosticados de fibrosis pulmonar idiop&#225;tica &#40;FPI&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio retrospectivo con los datos de pacientes con CFPE y FPI diagnosticados en nuestro centro en un periodo de 5 a&#241;os&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a 66 pacientes&#44; 29 en el grupo de CFPE y 37 pacientes con FPI&#46; Nueve ten&#237;an un diagn&#243;stico de CP &#40;6 con CFPE y 3 con FPI&#41;&#59; 6 pacientes &#40;67&#37;&#41; recibieron tratamiento paliativo a pesar de que 3 de ellos presentaban estadios <span class="elsevierStyleSmallCaps">i</span> y <span class="elsevierStyleSmallCaps">ii</span>&#46; No hubo diferencias significativas en la mortalidad global de los 2 grupos&#59; sin embargo&#44; en los pacientes con CP la supervivencia fue significativamente menor con respecto a los que no ten&#237;an CP &#40;p&#61;&#44;044&#41;&#46; Las causas m&#225;s frecuentes de muerte fue la insuficiencia respiratoria secundaria a la exacerbaci&#243;n de la fibrosis pulmonar &#40;44&#37;&#41;&#46; En el an&#225;lisis multivariante&#44; la <span class="elsevierStyleItalic">odds ratio</span> de morir en los pacientes con CP respecto a los pacientes sin CP fue de 6&#44;20 &#40;p&#61;&#44;037&#44; intervalo de confianza &#91;IC&#93; del 95&#37;&#58; 1&#44;11 a 34&#44;48&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El CP empeora la supervivencia de estas 2 entidades&#46; El manejo diagn&#243;stico y terap&#233;utico del CP se ve dificultado por el mayor riesgo de complicaciones posteriores al tratamiento elegido&#44; incluso tras el tratamiento paliativo&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Portillo K&#44; Perez-Rodas N&#44; Garc&#237;a-Oliv&#233; I&#44; Guasch-Arriaga I&#44; Centeno C&#44; Serra P&#44; et al&#46; C&#225;ncer de pulm&#243;n en pacientes con combinaci&#243;n de fibrosis pulmonar y enfisema y fibrosis pulmonar idiop&#225;tica&#46; Estudio descriptivo en una serie espa&#241;ola&#46; Arch Bronconeumol&#46; 2017&#59;53&#58;304&#8211;310&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patient with CPFE and LC&#46; &#40;A&#41; Chest radiograph &#40;posteroanterior projection&#41;&#58; Poorly defined nodular focal pulmonary opacity &#40;arrow&#41; is observed in the base of the left lung&#44; and a reticular interstitial involvement in both lung bases&#46; &#40;B&#41; HRCT showing presence of emphysema in the upper lobes&#46; &#40;C&#41; Chest HRCT confirming presence of a pulmonary mass with lobulated and spiculated borders &#40;arrow head&#41; in the lingula&#44; adjacent to an area of honeycombing&#46; CPFE&#58; combined pulmonary fibrosis and emphysema&#59; LC&#58; lung cancer&#59; HRCT&#58; high-resolution computed tomography&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Comparison of survival by presence of IPF or CPFE&#46; CPFE&#58; combined pulmonary fibrosis and emphysema&#59; IPF&#58; idiopathic pulmonary fibrosis&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Comparison of survival by presence or absence of LC&#46; LC&#58; lung cancer&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">6MWT&#58; 6-minute walk test&#59; &#37; pred&#58; percentage of predicted value&#59; AV&#58; alveolar volume&#59; CPFE&#58; combined pulmonary fibrosis and emphysema&#59; CPI&#58; composite physiologic index&#59; DL<span class="elsevierStyleInf">CO</span>&#58; diffusing capacity of the lung for carbon monoxide&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in 1 second&#59; FEV<span class="elsevierStyleInf">1</span>&#47;FVC&#58; forced expiratory volume in 1 second and forced vital capacity ratio expressed as an absolute percentage&#59; FVC&#58; forced vital capacity&#59; IPF&#58; idiopathic pulmonary fibrosis&#59; PH&#58; pulmonary hypertension&#59; RV&#58; residual volume&#59; RV&#47;TLC&#58; ratio of RV and total lung capacity&#59; SPB&#58; systolic blood pressure&#59; SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleInf">final</span>&#58; oxygen saturation at end of 6MWT&#59; SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleInf">initial</span>&#58; oxygen saturation at start of 6MWT&#59; TLC&#58; total lung capacity&#59; TR&#58; tricuspid regurgitation&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Data are presented as mean&#177;SD&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CPFE &#40;<span class="elsevierStyleItalic">n</span>&#61;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IPF &#40;<span class="elsevierStyleItalic">n</span>&#61;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&#177;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&#177;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&#47;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#47;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Active smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Former smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Never smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pack-years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#177;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#177;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FVC &#40;&#37; pred&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&#177;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#177;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FEV<span class="elsevierStyleInf">1</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&#177;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&#177;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FEV<span class="elsevierStyleInf">1</span>&#47;FVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&#177;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&#177;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TLC &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&#177;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#177;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RV &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">117&#177;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&#177;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RV&#47;TLC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">118&#177;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">94&#177;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;052&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DL<span class="elsevierStyleInf">CO</span> &#40;&#37; pred&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&#177;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#177;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DLCO&#47;AV &#40;&#37; pred&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&#177;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&#177;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CPI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&#177;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&#177;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6MWT &#40;m&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">369&#177;150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">421&#177;113&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleInf">initial</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95&#177;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96&#177;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleInf">final</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&#177;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&#177;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PH<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SBP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#177;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#177;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;047&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TR speed &#40;m<span class="elsevierStyleHsp" style=""></span>s<span class="elsevierStyleSup">&#8722;1</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;1&#177;0&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;4&#177;0&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">In accordance with the echocardiographic criteria of Gali&#232; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a></p>"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">ABI&#58; acute bronchial infection&#59; CVA&#58; cerebrovascular accident&#59; CPFE&#58; combined pulmonary fibrosis and emphysema&#59; chemoherapy&#58; chemotherapy&#59; CT-CNB&#58; computed tomography-guided core needle biopsy&#59; EBUS-TBNA&#58; real-time endobronchial ultrasound-transbronchial needle aspiration&#59; FB&#58; fiberoptic bronchoscopy&#59; IPF&#58; idiopathic pulmonary fibrosis&#59; LLL&#58; left lower lobe&#59; LUL&#58; left upper lobe&#59; M&#47;F&#58; male&#47;female&#59; MT&#58; metastasis&#59; NA&#58; not applicable&#59; PET-CT&#58; positron emission tomography-computed tomography&#59; PTE&#58; pulmonary thromboembolism&#59; RLL&#58; right lower lobe&#59; RUL&#58; right lower lobe&#59; RT&#58; radiation therapy&#59; SR&#58; surgical resection&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N&#46;&#176;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex &#40;M&#47;F&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Smoking Habit &#40;Yes&#47;No&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial Manifestation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic Technique&#47;Staging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pathology Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Site of Cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Stage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cause of Death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FB&#47;EBUS-TBNA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LLL &#40;adjacent to honeycombing&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exacerbation of pulmonary fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hemorrhagic CVA due to brain MT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ABI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FB&#47;EBUS-TBNA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Squamous carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RLL &#40;unaffected zone&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IIB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bronchoarterial fistula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hemoptysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mediastinoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RUL &#40;adjacent to emphysema&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SR&#43;chemoherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumothorax&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT-CNB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inconclusive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LUL &#40;lingula&#41; &#40;adjacent to honeycombing&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RT&#47;palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exacerbation of pulmonary fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Respiratory failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ABI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT-CNB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LUL &#40;adjacent to emphysema&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">chemoherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exacerbation of pulmonary fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Respiratory failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPFE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FB&#47;EBUS-TBNA<br>PET-CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inconclusive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left hilar lesion infiltrating pulmonary artery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IIIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PTE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sepsis of respiratory origin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IPF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inconclusive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RUL &#40;unaffected zone&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exacerbation of pulmonary fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Respiratory failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IPF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radiological finding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT-CNB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LUL &#40;adjacent to emphysema&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PTE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Respiratory failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IPF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ABI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Atypical cells suggestive of malignancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RUL &#40;adjacent to emphysema&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiorgan failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1459548.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Characteristics&#44; Treatment and Progress of Patients with Lung Cancer&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:40 [
            0 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Combined pulmonary fibrosis and emphysema&#58; a distinct underrecognised entity"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "V&#46; Cottin"
                            1 => "H&#46; Nunes"
                            2 => "P&#46; Brillet"
                            3 => "P&#46; Delaval"
                            4 => "G&#46; Devouassoux"
                            5 => "I&#46; Tillie-Leblond"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.05.00021005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2005"
                        "volumen" => "26"
                        "paginaInicial" => "586"
                        "paginaFinal" => "593"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16204587"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Combined apical emphysema and basal fibrosis syndrome &#40;emphysema&#47;fibrosis syndrome&#41;&#58; CT imaging features and pulmonary function tests"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;Y&#46; Brillet"
                            1 => "V&#46; Cottin"
                            2 => "P&#46; Letoumelin"
                            3 => "F&#46; Landino"
                            4 => "M&#46;W&#46; Brauner"
                            5 => "D&#46; Valeyre"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Radiol"
                        "fecha" => "2009"
                        "volumen" => "90"
                        "paginaInicial" => "43"
                        "paginaFinal" => "51"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19182713"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Idiopathic pulmonary fibrosis and emphysema&#58; decreased survival associated with severe pulmonary arterial hypertension"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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Article information
ISSN: 15792129
Original language: English
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