Discussion
The case report shows a rare association of FSGS and malignant neoplasia
and even more rare is this type of paraneoplastic nephrotic syndrome
correlated with the presence of melanoma. In this case, we observed a
clear association between the onset of nephrotic syndrome months after
the diagnosis of melanoma in the right hallux region, but there was no
evidence of metastasis.
Due to the clinical picture of hematuria, anasarca and symptoms
resulting from anasarca (orthopnea, dyspnea on exertion), diagnostic
tests were performed to confirm the presence of nephrotic syndrome with
proteinuria greater than 3.5 g/24 hours and hypoalbuminemia.
The second step in this case was to identify which the etiology of
nephrotic syndrome for better directs treatment. With the extensive
complementary investigation, no other factor was identified besides the
presence of cancer.
The association of melanoma with this patient’s nephrotic syndrome
became even more evident when proteinuria worsened, even under
cyclosporine treatment, with local tumor recurrence, lymph nodes, and
pulmonary metastasis. And the improvement of symptoms when introduced
lymphadenectomy and radiotherapy right inguinal and right hallux with
chemotherapy adjuvant with carboplatin and paclitaxel.
A therapeutic dilemma in this case was to initiate and maintain
cyclosporine in a patient with tumor recurrence to control the
paraneoplastic syndrome. Studies indicate that the treatment of FSGS
with corticosteroids is effective in less than 50% of cases and due to
this reason, the use of immunosuppressants should associated with
corticosteroid. In this patient was used prednisone 0.5 mg/kg/day and
cyclosporine and 100mg 12/12h, even though the patient is
immunosuppressed due to the neoplastic process. And it has been
recommended therapy immunosuppressant with established as early as
possible with the aim of avoiding or aggravate the development of kidney
failure, a result expected in the event of unsuitable treatment of FSGS,
which deteriorate the prognosis of the patient.
Cyclosporin withdrawal was performed when the 24-hour proteinuria
reached non-nephrotic values confirming the control of FSGS. The patient
was discharged with outpatient follow-up, remained asymptomatic. As
noted above and exist few studies exposing the outcome d the treatment
in cases of paraneoplastic FSGS, and this is due to the rarity of this
association. In case it was not possible curative treatment of melanoma
, but the control of the disease with the combined use of
corticosteroids and cyclosporine , h hears remission of nephrotic
syndrome without the complications associated with these cases and
improves the patient’s quality of life during the period of melanoma
treatment.