(19)
The choice of paraneoplastic glomerulopathy therapy
depends on the etiology, which can be used: low salt diet, water
restriction, diuretics, ACE inhibitor, corticosteroids,
immunosuppressants (azathioprine, cyclosporine), chemotherapy (in cases
of unresectable tumors or metastasis). Complete tumor resolution
promotes total resolution of paraneoplastic nephrotic syndrome, but its
treatment is complicated in cases of difficult tumor therapy or in cases
of metastatic tumors, and the use of corticosteroids and
immunosuppressants for nephrotic syndrome is highly debatable,
especially in cancer patients. In cases where the association of cancer
with glomerulopathy is not very well established. (1, 2, 10,
20)
This study aims to report a case report of a patient with FSGS and
metastatic melanoma and the association between segmental and focal
glomerulosclerosis (FSGS) and cancer; to analyze possible diagnostic
methods available to obtain the association between FSGS in cancer
patients and to evaluate the role of immunosuppression as the most
appropriate treatment for cancer patients with nephrotic syndrome (NS) .
Clinical case
Patient 56 years old, married, from Bahia (Brazil), catholic and farmer.
Patient sought hospital service in January 2013 due to an ulcerated
lesion on the first right toe that had appeared one year ago. A biopsy
of the lesion identified invasive malignant melanoma (Breslow 5.8 mm and
Clark V) in the presence of involved margins. After nine days amputation
of the right hallux with margin resection was performed. On physical
examination he was conscious, feverish. At this time no abnormalities
were detected on pulmonary, cardiovascular, abdomen and neurological
examination.
After seven months (July 2013) admitted in due to a frame diarrhea,
anasarca, dyspnea on little exertion, orthopnea, dry cough, and
hematuria. On physical examination, lower limb edema and ascites were
identified. Diagnostic hypothesis of nephrotic syndrome made and
examinations for investigation of the condition.
The examinations for the diagnosis and research of the above are: urea
57 mg/dL, creatinine 1.22 mg/dL, GFR measured at 24 h urine: 40.0
mL/min/1.73m²; uric acid: 6 mg/dL, Na: 142 mEq/L, K: 5.6 mEq/L,
bicarbonate: 28 mmol/L, ionic Ca: 4.7 mg/dL; P: 4.2 mg/dL; PTH: 135
pg/mL, Vitamin D: 8 ng/ml, glycemia 79 mg/dL, glycated hb: 5% . And
evaluating possible nephrotic syndrome has been identified in
proteinuria 10.76 g/24 hours, albumin serum of 2g/L.
For the differential diagnosis of the condition were also dosed : native
anti-DNA antibody 16 U/ml, FAN HEP2: homogeneous nuclear standard with
titer 1/160 and nucleus 1/160, fibrinogen: 1067 mg/dL, rheumatoid
factor: 11, 9 IU/ml, serology for treponema pallidum, hepatitis B and C,
HIV: nonreactive, anti-VCA IgM and IgG: nonreactive, complement fraction
C3: 147 mg/dL, complement fraction C4: 31.1 mg/dL, immunofixation with
absence of anomalous proteins .
Given the need to complete the etiology of NS, a renal biopsy was
performed, which revealed the presence of segmental and focal
glomerulosclerosis (FSGS) as shown in figures 1, 2 and 3, tip lesion -
regenerating acute tubular necrosis (focal) and negative
immunofluorescence.
Thus, treatment with prednisone 0.5 mg/kg and cyclosporine 100mg 12/12h
on 08/21/13 was instituted during this same period, a reduction in
proteinuria (1g/24h) was also identified.
After ten months, she went to the hospital in March 2014 due to the
appearance of a foot injury D, which was resected. In October 2014, the
patient presented with right inguinal lymph node enlargement. A USG was
performed in which: inguinal lymph node with focal cortical thickening,
measuring 13x6mm and globular morphological inguinal lymph node,
measuring diffuse cortical thickness measuring 15x9mm. The aspiration
lymph node inguinal right it was positive the neoplastic cells. Tests
for staging detected on CT chest with micronodule lung pulses, non-
specific, neural plate and pleural thickening irregular left and
axillary lymph nodes increased in number. Thus, right inguinal
lymphadenectomy, right inguinal radiotherapy for four months, right
hallux radiotherapy and carboplatin and paclitaxel chemotherapy were
instituted.
Due to a new elevation of proteinuria levels with the presence of tumor
recurrence, a cyclosporine treatment was prolonged, which was withdrawn
only after 19 months of treatment. Cyclosporine withdrawal was performed
slowly and was withdrawn on 04/04/2015 when 24-hour proteinuria reached
values <0.4 g / L and GFR: 92 ml/min/1.73m² .