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"note_text": "En Mayo de 1997, una mujer de 29 años de edad fue intervenida, en otro centro, de un carcinoma de la glándula suprarrenal izquierda clínicamente no funcionante que se manifestó clínicamente como molestias en el flanco izquierdo, poco específicas, en el postparto inmediato; la ecografía y la tomografía axial computerizada abdominales mostraron una masa suprarrenal izquierda de 10 cmts., sólida y con áreas de calcificación y necrosis en su interior, siendo la radiografía de tórax y la gammagrafía ósea normales. En los análisis, presentaba ligero aumento de la cortisoluria (284.5 mcgr./24h.) y de 17-OH-esteroides en orina (12.7 mcg./24h.), sin síntomas de hipercortisolismo sistémico. Se realizó resección completa de la tumoración, con el diagnóstico histológico de carcinoma suprarrenal de 10 x 7 x 5 cmts. (215 grs.) bien encapsulado, aunque con invasión vascular, amplias zonas de necrosis y un índice mitótico de 5.8/50; el estudio histoquímico fue (+) para Vimentina y (-) para Citoqueratina, EMA, Cromogranina y Sm- 100. Se etiquetó como Estadio II y Grado II. Treinta meses después, la paciente presentó en los estudios radiológicos de seguimiento una masa en el lecho de resección previo de 7 cmts., en contacto con el hilio renal izquierdo y técnicamente resecable; se reintervino y se llevó a cabo una resección de la recidiva asociada a nefrectomía izquierda, esplenectomía y pancreatectomía distal (radical completa y con márgenes libres). Posteriormente, recibió tratamiento quimioterápico sistémico adyuvante con 6 ciclos completos de cisplatino (CDDP) y etopósido (VP-16) en régimen adyuvante.\n Cuatro años y once meses tras el tratamiento inicial, se detecta en el seguimiento radiológico la presencia de varios nódulos hepáticos sugerentes de metástasis. Se sometió de nuevo a cirugía abdominal realizándose, previo control con ecografía hepática intraoperatoria, una bisegmentectomía IV-B y V y una resección limitada del segmento VIII; el análisis de anatomía-patológica informó de la presencia de 7 nódulos (de tamaño variable entre 0.5 y 1.5 cmts.) compatibles con metástasis de carcinoma suprarrenal.\n Diez meses después, se detecta una nueva recidiva tumoral a nivel subdiafragmático izquierdo (de 6 x 4 cmts. según la TAC) y en la raiz del mesenterio, esta última de 4 x 3 cmts. y localizada a nivel de la salida de la arteria mesentérica superior (AMS). Dada la difícil resecabilidad de la nueva recidiva se decide tratamiento quimioterápico con intención neoadyuvante ( 5 ciclos completos de CDDP y VP-16), decidiéndose por regresión parcial de las lesiones una nueva exploración quirúrgica. Se realizó la resección de las dos masas tumorales, la primera incluyendo el pilar izquierdo del diafragma y una pastilla de 5 cmts. de dicho músculo, y la segunda disecando en su origen el tronco celíaco y la AMS y resecando todo el tejido tumoral entre ambos vasos. La anatomía patológica confirmó la recidiva, estando los bordes de resección no afectos. La evolución postoperatoria fue satisfactoria.\n La paciente se encuentra, tras 7 años y 3 meses del diagnóstico del tumor primario, libre de enfermedad y con una calidad de vida aceptable, mínimamente limitada por las deposiciones diarreicas secundarias a la denervación simpática celíaca.\n",
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"note_text": "Paciente de 51 años diagnosticado 20 años antes de Neurolues, con secuelas establecidas tipo trastornos mnésicos visuales y verbales, así como radiculoneuropatía múltiple. En la radiología de tórax presentaba elongación aórtica sin repercusión clínica. Se realizó electroencefalograma con trazado normal, y en el TC craneal con y sin contraste mostró una morfología cerebral dentro de límites normales. La serología para Lues en los test RPR y TPHA fueron positivos. El ácido fólico y la vitamina B12 estaban dentro del rango de la normalidad.\n El paciente fue derivado a nuestras consultas de Urodinámica por trastornos miccionales refiriendo incontinencia por urgencia, no precisando de prensa abdominal para el vaciado vesical. Se realizó estudio urodinámico objetivándose un detrusor hiperrefléxico con presiones altas y contracciones involuntarias no inhibidas que ocasionaban escapes; la curva de Presión/ Flujo no mostraba alteraciones. Con el diagnóstico de detrusor hiperactivo de causa neurogénica se inició tratamiento con anticolinérgicos, estando en la actualidad estable clínicamente con urgencia ocasional sin incontinencia.\n \n",
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