(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 .