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.